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Social media is now a daily part of all our lives. It can not only be entertaining and informative, but it also has the potential to help your career as a nurse and the nursing profession in general.

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Social media is now a daily part of all our lives. It can not only be entertaining and informative, but it also has the potential to help your career as a nurse and the nursing profession in general.

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Original Paper

¹ Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States

² Harvard Medical School, Boston, MA, United States

³ College of Nursing and Health Sciences, University of Massachusetts, Boston, MA, United States

⁴ David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, United States

⁵ Division of General Internal Medicine, School of Medicine, University of Washington, Seattle, WA, United States

⁶ Department of Medicine, Medicine Information Technology Services, University of Washington, Seattle, WA, United States

⁷ Steele Institute for Health Innovation, Geisinger, Danville, PA, United States

*these authors contributed equally

Corresponding Author

Corresponding Author:

Jan Walker, RN, MBA

Division of General Medicine

Beth Israel Deaconess Medical Center

133 Brookline Avenue HV-2200

Boston, MA, 02215

United States

Phone: 1 517 975 7616

Email: jwalker1@bidmc.harvard.edu

Related Article:

This is a corrected version. See correction statement in: https://www.jmir.org/2020/4/e18639/

ABSTRACT

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

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

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

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

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

J Med Internet Res 2019;21(5):e13876

doi:10.2196/13876

Citation

Please cite as:

Loading authors...

KEYWORDS

Introduction

Secure Patient Portals

Patients who engage and participate actively in their health care appear to achieve better health outcomes and incur lower health care costs []. In part, to stimulate such engagement, the US federal government passed a legislation in 2009 incentivizing doctors and health systems to adopt new technologies offering patients electronic access to their health data via secure electronic patient portals []. Patients were invited to review their test results and problem and medication lists and, in many cases, to send secure messages to their clinicians. However, very few offered patients access to the notes written by their clinicians during or following face-to-face encounters.

The OpenNotes Initiative

In 2010, the Robert Wood Johnson Foundation funded the OpenNotes initiative, designed initially to examine the feasibility and effects of having primary care physicians (PCPs) share their notes routinely with patients. For 12 months, PCPs invited patients registered on portals to read these notes and 105 doctors and 5500 of their patients subsequently completed surveys. Representing 3 geographically dispersed and very different health care settings, the respondents were highly positive, with patients reporting a wide range of clinically important benefits and doctors noting little impact on their workflow []. Subsequent studies extending beyond primary care to medication adherence, inpatient care, oncology, mental illness, and other specialties suggested similar benefits, and in recent years, the practice of inviting patients to review their clinicians' notes has spread [-]. Presently, US clinicians offer more than 38 million patients electronic access to their notes through patient portals, policy makers are considering mandating such practice, and fully transparent records are spreading in several other nations [-]. Many prominent American institutions now offer open notes in the vast majority of their ambulatory practices, including medical and surgical offices and those focusing on mental illness. However, at this point, we know little about patient experiences with open notes over time throughout the broad spectrum of ambulatory care.

Following their initial limited experiment in primary care, the 3 institutions that originally piloted OpenNotes adopted the practice throughout, and many of their patients have grown accustomed to reading notes following visits to nearly all clinicians in their associated primary care, medical, surgical, and mental health practices. On the basis of the reports and observations over the past few years, we developed 4 primary hypotheses: (1) over time, patients would continue to report important benefits from reading visit notes; (2) patients would often share or discuss notes with others; (3) those traditionally at risk for experiencing substandard care would report the greatest benefit; and (4) patients and clinicians would communicate about these notes actively during visits. We report findings from a large survey of patients conducted in the institutions that participated in the pilot OpenNotes inquiry.

Methods

Setting

We conducted a Web-based survey of patients who had been seen in hospital offices and community practices at 3 health systems: Beth Israel Deaconess Medical Center (BIDMC), an urban academic health system in and around Boston; Geisinger, a large rural integrated health system in Pennsylvania; and University of Washington Medicine (UW) in Seattle, which includes both private and community-funded safety net practices affiliated with the University of Washington. All 3 systems participated in the original 2010-2011 OpenNotes pilot involving PCPs [] and, by 2014, all 3 had expanded open notes to virtually all outpatient offices and clinicians, thereby providing access to visit notes in specialty as well as primary care settings. Open notes became the standard for virtually all types of outpatient clinicians who sign notes in the patient's medical record, including doctors, physical, occupational, speech, and other types of therapists, dieticians, nurses, nurse practitioners, and physician assistants. At the same time, the systems developed policies allowing some individual clinicians to opt out of participation and enabled participating clinicians to manually block the release of individual notes to the patient portal []. BIDMC and UW sent automated email messages informing patients when new notes were made available, but Geisinger did not []. At the time of the survey, somewhat fewer than half of all ambulatory patients were registered for the patient portal at each site (personal communications from Rebecca Stametz and Thomas Payne, July 24, 2018, and Amy Goldman, July 25, 2018).

Participants

The survey included patients seen in primary care and specialty offices: at the hospital and 6 affiliated sites at BIDMC, at 3 hospitals and 9 freestanding offices at UW, and at 7 hospitals and 53 outlying practices at Geisinger. Eligible patients were aged 18 years or older, had logged into the portal at least once in the previous 12 months, and had at least 1 ambulatory visit note available in the previous 12 months. We excluded patients who had been invited to participate in focus groups or other surveys related to OpenNotes within the preceding 12 months. Using portal tracking data, we identified patients who had, and had not, accessed available visit notes in the previous 12 months and described them as readers and nonreaders, respectively. We did not exclude nonreaders because we wanted to gain some understanding of why they had not read the notes. BIDMC and UW included all eligible readers and a random sample of eligible nonreaders in the survey sample. For administrative reasons, Geisinger drew random samples from both groups, resulting in smaller samples than the other 2 sites. Across the 3 sites, 109,904 readers and 27,959 nonreaders were sent invitations for the survey. The Institutional Review Boards at BIDMC, Geisinger, and UW approved the survey and study protocol at their respective sites.

Constructing the Questionnaire

This survey draws heavily on questions used in the original demonstration project in primary care; its development has been previously described []. We updated the questionnaire based on comments from outside reviewers, focus groups with diverse patients from a community health center, assessment of the distribution of responses in the original study, and an evaluation of psychometric properties of different versions of some of the items, including those related to benefits and risks of reading notes (manuscript under review). Except for a few site-specific modifications, the questionnaire was the same for all patients, and with the exception of skip patterns, free text, and demographic questions, all items required a response. Both the original and updated versions are available on request from the authors.

Conducting the Survey

We surveyed patients between June and October 2017, using a Web-based survey platform, Survey Gizmo. Patients were sent invitations by email either to their portal accounts or to the personal email address associated with the accounts. Each patient's invitation contained his or her study identification embedded in a unique link to the survey, and each study identification could be used only once. Following the original invitation, patients received 2 reminders 1 week apart if they had not completed the survey. Knowing that patients sometimes confuse notes with other parts of the medical record, or with the portal itself, we described clinical notes in both the survey invitation and in a survey question and we also showed a screenshot of the location of visit notes on their institutions' portals to increase the likelihood that patients would report on visit notes. Knowing also that invitations might be opened by care partners rather than patients, each respondent had an option to complete the survey as a patient or as a care partner, and care partners were automatically linked to a different questionnaire. We offered respondents an incentive for completing the survey: a raffle of 50 prizes of US $25 or US $50 at each site.

Statistical Analysis

To maximize the chances that we were including responses about clinical notes rather than another part of the record, as a final step, we excluded responses from patients whose self-report of note reading in the past 12 months did not match portal data; for example, patients reported they had read notes, but the portal tracking data showed they had not. We also excluded respondents who reported reading notes for a week or less, or did not answer the question about length of time reading notes, since our objective was to assess patients' experiences over the prior 12 months. Except as noted in the tables, all questions included in this analysis had < 4% missing responses, and denominators include all nonmissing responses to each item. Items related to medication management are addressed in another paper [].

Most items addressing potential benefits and risks asked for ratings on an 11-point scale, ranging from 0 (not at all important, confusing, or concerned) to 10 (extremely important, confusing, or concerned). Responses to these items were collapsed into 4 categories a priori for analysis: 0-1, 2-4, 5-7, and 8-10, and we reported the 8-10 category as very important, confused, or concerned. Four-level agreement responses were dichotomized as agree or somewhat agree, and disagree or somewhat disagree.

Using percentages and chi-square tests, we compared respondents with nonrespondents using administrative data available at each institution: age and sex at all 3 sites, Hispanic ethnicity at Geisinger and UW, and insurance type at BIDMC and Geisinger.

We used descriptive statistics to examine respondents' sociodemographic and health characteristics and experiences with note reading, both overall and stratified by study site. We used the chi-square test for independence (degrees of freedom: row-1 × column-1) to test for differences according to demographic characteristics in patients' experiences in note reading. We performed a multivariable analysis using log Poisson regression models to estimate overall relative risks and 95% CIs for reporting benefits as very important according to patient characteristics, adjusted for other sociodemographic and health characteristics and number of notes read. Owing to the large sample size, we expected even slight differences between groups to be statistically significant. Therefore, we interpreted intercategory differences in proportions or relative risks of 10% or more as meaningful differences. All analyses were completed using SAS software version 9.4 (SAS Institute Inc).

Results

Participants

Of 136,815 patients who received survey invitations, 21.68% (29,656/136,815) responded; 28,782 were patients, and 874 were care partners (). Compared with nonrespondents, respondents were older at all 3 sites. At BIDMC and UW, white patients were more likely to respond than nonwhite patients. No differences were noted between responders and nonresponders regarding sex at any of the 3 sites, regarding Hispanic ethnicity at UW and Geisinger, and regarding insurance type at BIDMC and Geisinger (data not shown).

Of the 28,782 patient respondents, 62.82% (18,081/28,782) were female; 72.90% (20,982/28,782) were aged 45 years or older; 76.94% (22,146/28,782) were white; 53.06% (15,271/28,782) were employed; and 14.30% (4115/28,782) reported fair or poor general health. Overall, 64.92% (18,685/28,782) had completed college, but the sites differed substantially: the proportion of those with a high school education or less was 4.8% (655/13,613) at BIDMC and 5.4% (708/13,119) at UW, but 25.9% (530/2050) at Geisinger.

‎
Figure 1. Study flow diagram. BIDMC: Beth Israel Deaconess Medical Center; UW: University of Washington Medicine.
View this figure

Accessing and Reading Notes

After note reading exclusions, 23,710 responses were included in the analysis: 22,947 note readers and 763 nonreaders. Among note readers, three-quarters reported reading notes for a year or more and half reported reading 4 or more notes. In general, they reported locating notes easily on the portals and considered email notifications about new notes useful. About one-third of readers at BIDMC (4065/11,899, 34.16%) and UW (2998/9719, 30.85%), but only 20.1% (237/1178) at Geisinger, reported mentioning to their clinicians that they had read a note, and about the same proportion (7324/22,798, 32.13%) said they were encouraged by their clinicians to read notes. Among those who were encouraged, 60% read 4 or more notes compared with 46% of those who were not encouraged to read notes. In total, 37.74% (8588/22,753) reported sharing or discussing a note with a family member or someone else. Overall, 98.46% (22,593/22,947) of readers thought making notes available to patients a good idea, and 62.38% (13,427/21,525) said access to visit notes would be very important in choosing a future provider.

Benefits and Risks of Note Reading

As shown in , between 50.43% (11,346/22,514) and 72.62% (16,354/22,520) of patients in all sites combined rated note reading as very important for helping them achieve 6 different benefits. In contrast, 3.3% (737/22,304) said they were very confused by their notes, 4.83% (1078/22,303) reported being more worried after reading notes, and 11.46% (2529/22,067) reported being very concerned about privacy. The positive perceptions of benefits were evident across the 3 sites, with patients in rural Pennsylvania reporting the highest ratings of importance of note reading.

We found meaningful differences (≥ 10%) in patients' perceptions of the benefits of reading notes according to sociodemographic characteristics (). Black patients were more likely than white patients to rate note reading as very important for 5 of the 6 benefits and patients aged 45 years or older rated it very important for 4 of the benefits compared with those aged 18 to 24 years. Those who usually spoke a language other than English at home were more likely than English speakers to use notes to make the most of visits, remember the plan of care, and prepare for visits. Patients with the fewest years of education and Hispanic patients were more likely than others to cite note reading as very important for remembering the care plan and preparing for visits. Patients who read a greater number of notes were more likely to cite reading notes as very important for all 6 benefits.

Few patients reported being very confused or more worried from reading notes, with only minor differences according to sociodemographic characteristics (). Though differences did not reach the 10% threshold, greater proportions of black patients, Asians, and other minorities reported being very concerned about privacy related to open notes, 16.2% (174/1076) to 19.2% (104/543), compared with 10.15% (1828/18,012) of white patients.

After adjusting for other factors, education level continued to be inversely associated with patient ratings of the importance of note reading for all 6 benefits (). Similarly, after adjusting for other characteristics, black patients were more likely than white patients to rate note reading as very important for achieving benefits. Older patients-especially those aged > 45 years-were more likely to rate notes as important for 4 of the benefits. Hispanic patients and those who spoke a language other than English at home found notes very important for 3 benefits. Notably, the importance of note reading in preparing for office visits was the benefit most endorsed among more vulnerable demographic groups.

When we asked the 763 nonreaders about the main reason they had not looked at visit notes, about half selected, I forgot or did not know my visit notes were available. A total of 10.4% (79/761) indicated they did not know they had a right to look at notes, 8.8% (67/761) were too busy, 7.2% (55/761) did not think reading would be useful, and 6.3% (48/761) were not able to find the notes. Among the 12.0% (95/761) reporting another reason, the majority wrote that they had no need to read notes because they trusted their clinicians, had received printed copies, or had no health issues or recent visits. Only 9.1% (69/760) of nonreaders reported being encouraged by a clinician to read their notes. We found no material differences in demographic characteristics in the nonreaders compared with the readers (data not shown). Even though they had not read notes, 89.0% (679/763) of nonreaders agreed that making notes available to patients on the Web is a good idea.

‎
Figure 2. Benefits and risks of reading notes. BIDMC: Beth Israel Deaconess Medical Center; UW: University of Washington Medicine.
View this figure

‎
Table 1. Proportion of patients identifying notes as extremely important in achieving benefits.
View this table

‎
Table 2. Proportions of patients reporting risks from reading notes.
View this table

‎
Table 3. Adjusted relative risk and 95% CI of identifying notes as very important for potential benefits.
View this table

Discussion

Principal Findings

In this study, the largest assessment to date of patients who read a wide variety of clinicians' notes over time, patients report that reading clinical notes brings them substantial benefit. The respondents represent urban and rural settings, varying education levels, and broad age and racial distributions, and they had access to notes composed by most clinicians providing primary care and ambulatory care in medical, surgical, and mental health specialties. About two-thirds of patients describe notes as extremely important in increasing their sense of control, improving recall and understanding of their plans for care, and better preparing them for visits. Few reported confusion or increased worries, and those patients from medically underserved groups reported the most benefit. Whether or not they chose to review their notes, patients overwhelmingly approved the practice, with a majority reporting that access to notes would be extremely important in determining their future choice of clinicians. On the contrary, only a third of patients recalled discussing their notes during visits or having their clinicians recommend that they read them.

Comparison With Other Studies

These reports from almost 23,000 patients who read their notes amplify and reinforce the findings from smaller, more targeted, and shorter studies within primary care practices and discrete clinical specialties [-,,,,]. Many respondents had read notes over several years, and these results may foretell a steady state of patient experiences over the longer term. The high proportion of patients reporting benefits from reading notes did not diminish compared with our first survey in primary care patients several years ago, and more patients reported mentioning their note reading to their providers (32%, up from 19%) [].

Implications of the Findings

Focusing on clinically important process measures, these results strongly suggest that transparency helps patients feel more engaged in their care. This is an important finding, given that a growing body of evidence indicates that engaged patients are more likely to adhere to treatment plans and medications, follow through on screening and prevention protocols, detect and prevent errors, and adopt more effective management strategies for chronic illnesses [-].

Although the time-honored principle of patient-clinician confidentiality is not in itself affected by open notes, it is up to patients to decide whether or not to disclose their medical information to others. More than a third of respondents reported sharing notes with someone else, almost twice the rate reported in 2012 in the study of primary care patients in the same institutions []. Shared notes may be particularly helpful to informal care partners [,] and to those in search of informal second opinions from both lay and professional associates.

In this survey, patients who are potentially the most vulnerable-those who are older, less educated, non-white, Hispanic, or not English speakers at home-reported the most benefit. By virtue, both of taking the initiative to sign onto a patient portal and reading their notes, they may not be representative of other Americans with similar demographics, as is true for everyone in our sample. But this finding extends and amplifies findings in earlier inquiries [-,,,,,]. Vulnerable patients may come to a visit with a lower baseline sense of control and knowledge than others; they may also have more difficulty understanding or retaining what practitioners say or emphasize. Assisted at times by family members or other acquaintances who can help interpret and research points made in notes, the possibility of review in their homes may contribute to their particular enthusiasm for this new opportunity. Moreover, in several studies, patients who are disadvantaged may trust their health professionals less than those with social and educational backgrounds similar to their clinicians []. Shared notes can increase trust, as studies and anecdotes from both patients and clinicians suggest [,]. That particularly vulnerable patients may gain the most from open notes is worthy of further inquiry. Similarly, the fact that minority patients are more concerned about privacy than white patients also deserves further study.

As some of our findings suggest, embedding open notes into clinical practice faces many challenges. Even in these 3 mature institutions, the majority of their patients have not registered on their patient portals, and half of the responding nonreaders did not know that notes were available-even though they were using their portals for other purposes. Moreover, contrary to our predictions, interchange in the clinician's office about past notes was infrequent. Here, there were also substantial differences across the sites. Patients from rural Pennsylvania were less likely than those in Boston and Seattle to report speaking with their providers about note reading. However, they were also more likely to report benefits from reading, including greater feelings of control of their care and better preparation for office visits. Access to clinicians' notes may offer particular benefits to rural populations, a possibility that warrants further study.

Strengths and Limitations

This is a cross-sectional study examining patients' self-reported experiences from only 3 regions of the United States, and results may not be generalizable to other regions or practices. Moreover, the response rate was modest, although it was similar to the response rate in a recent Consumer Assessment of Healthcare Provider and Systems survey []. It is possible that the survey respondents were those most enthusiastic about open notes. Although there were some demographic differences between responders and nonresponders, these differences were small, and the size of the sample analyzed gives further weight to the findings. It should be noted also that the majority of respondents were white, in good health, and highly educated. It is difficult to draw firm conclusions about the benefits to non-English speakers because the survey was only offered in English; subsequent surveys could be administered in other languages and also explore issues of health literacy. Finally, the literature on the impact of portals on patients is often confused by lack of specificity about different functionalities. A strength of our study is that we took several steps to make sure patients had experience reading notes and were reporting on reading visit notes, rather than on other information available on their portals.

Unanswered Questions and Future Directions

Some argue today that fully open medical records are simply ...the right thing to do, and this large survey of patients furnishes further evidence that their benefits outweigh their risks, certainly from the point of view of patients. Although the findings confirm that the benefits of note reading extend beyond primary care practices to virtually all specialties and types of clinicians, more needs to be learned about using open notes as a tool for communication and promoting interaction between patients and clinicians across health care venues and populations. The Department of Health and Human Services has proposed new rules that would increase patient access and control of their medical information, and easy electronic access to notes could become the law of the land []. To what degree can active educational interventions help patients learn optimally from what their records document? And in the future, might patients also contribute to their records by providing interval histories and articulating their goals for a visit in their own words, thereby enriching narratives, promoting focused interactions, and hopefully off-loading work from beleaguered clinicians? [].

At a time when medical practice in the United States is moving toward shared notes as a new standard, the patients participating in this study offer both affirmative and provocative reports, but building shared notes into the fabric of care remains a work in progress.

Acknowledgments

The authors thank the Robert Wood Johnson Foundation, Gordon and Betty Moore Foundation, Peterson Center on Healthcare, and Cambia Health Foundation for their financial support, as well as James Ralston, MD, MPH, Lee Hargraves, PhD, and Julie A Wright, PhD, for insightful comments on drafts of the questionnaire. The authors are also grateful to the patients for their input and responses and to all the colleagues on the OpenNotes team.

Conflicts of Interest

All authors had financial support for the submitted work from the Robert Wood Johnson Foundation, Gordon and Betty Moore Foundation, Peterson Center on Healthcare, and Cambia Health Foundation. The funders had no role in designing or conducting the study, analyzing the data, preparing the manuscript, or deciding to submit this manuscript for publication.

‎
Abbreviations

BIDMC: Beth Israel Deaconess Medical Center

PCP: primary care physician

UW: University of Washington Medicine

Edited by G Eysenbach; submitted 01.03.19; peer-reviewed by S Wolver, D Klein; comments to author 20.03.19; revised version received 01.04.19; accepted 02.04.19; published 06.05.19

©Jan Walker, Suzanne Leveille, Sigall Bell, Hannah Chimowitz, Zhiyong Dong, Joann G Elmore, Leonor Fernandez, Alan Fossa, Macda Gerard, Patricia Fitzgerald, Kendall Harcourt, Sara Jackson, Thomas H Payne, Jocelyn Perez, Hannah Shucard, Rebecca Stametz, Catherine DesRoches, Tom Delbanco. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 06.05.2019.

This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in the Journal of Medical Internet Research, is properly cited. The complete bibliographic information, a link to the original publication on http://www.jmir.org/, as well as this copyright and license information must be included.

Related Article:

This is a corrected version. See correction statement in: https://www.jmir.org/2020/4/e18639/

ABSTRACT

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

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

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

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

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

J Med Internet Res 2019;21(5):e13876

doi:10.2196/13876

Citation

Please cite as:

Loading authors...

KEYWORDS

Introduction

Secure Patient Portals

Patients who engage and participate actively in their health care appear to achieve better health outcomes and incur lower health care costs []. In part, to stimulate such engagement, the US federal government passed a legislation in 2009 incentivizing doctors and health systems to adopt new technologies offering patients electronic access to their health data via secure electronic patient portals []. Patients were invited to review their test results and problem and medication lists and, in many cases, to send secure messages to their clinicians. However, very few offered patients access to the notes written by their clinicians during or following face-to-face encounters.

The OpenNotes Initiative

In 2010, the Robert Wood Johnson Foundation funded the OpenNotes initiative, designed initially to examine the feasibility and effects of having primary care physicians (PCPs) share their notes routinely with patients. For 12 months, PCPs invited patients registered on portals to read these notes and 105 doctors and 5500 of their patients subsequently completed surveys. Representing 3 geographically dispersed and very different health care settings, the respondents were highly positive, with patients reporting a wide range of clinically important benefits and doctors noting little impact on their workflow []. Subsequent studies extending beyond primary care to medication adherence, inpatient care, oncology, mental illness, and other specialties suggested similar benefits, and in recent years, the practice of inviting patients to review their clinicians' notes has spread [-]. Presently, US clinicians offer more than 38 million patients electronic access to their notes through patient portals, policy makers are considering mandating such practice, and fully transparent records are spreading in several other nations [-]. Many prominent American institutions now offer open notes in the vast majority of their ambulatory practices, including medical and surgical offices and those focusing on mental illness. However, at this point, we know little about patient experiences with open notes over time throughout the broad spectrum of ambulatory care.

Following their initial limited experiment in primary care, the 3 institutions that originally piloted OpenNotes adopted the practice throughout, and many of their patients have grown accustomed to reading notes following visits to nearly all clinicians in their associated primary care, medical, surgical, and mental health practices. On the basis of the reports and observations over the past few years, we developed 4 primary hypotheses: (1) over time, patients would continue to report important benefits from reading visit notes; (2) patients would often share or discuss notes with others; (3) those traditionally at risk for experiencing substandard care would report the greatest benefit; and (4) patients and clinicians would communicate about these notes actively during visits. We report findings from a large survey of patients conducted in the institutions that participated in the pilot OpenNotes inquiry.

Methods

Setting

We conducted a Web-based survey of patients who had been seen in hospital offices and community practices at 3 health systems: Beth Israel Deaconess Medical Center (BIDMC), an urban academic health system in and around Boston; Geisinger, a large rural integrated health system in Pennsylvania; and University of Washington Medicine (UW) in Seattle, which includes both private and community-funded safety net practices affiliated with the University of Washington. All 3 systems participated in the original 2010-2011 OpenNotes pilot involving PCPs [] and, by 2014, all 3 had expanded open notes to virtually all outpatient offices and clinicians, thereby providing access to visit notes in specialty as well as primary care settings. Open notes became the standard for virtually all types of outpatient clinicians who sign notes in the patient's medical record, including doctors, physical, occupational, speech, and other types of therapists, dieticians, nurses, nurse practitioners, and physician assistants. At the same time, the systems developed policies allowing some individual clinicians to opt out of participation and enabled participating clinicians to manually block the release of individual notes to the patient portal []. BIDMC and UW sent automated email messages informing patients when new notes were made available, but Geisinger did not []. At the time of the survey, somewhat fewer than half of all ambulatory patients were registered for the patient portal at each site (personal communications from Rebecca Stametz and Thomas Payne, July 24, 2018, and Amy Goldman, July 25, 2018).

Participants

The survey included patients seen in primary care and specialty offices: at the hospital and 6 affiliated sites at BIDMC, at 3 hospitals and 9 freestanding offices at UW, and at 7 hospitals and 53 outlying practices at Geisinger. Eligible patients were aged 18 years or older, had logged into the portal at least once in the previous 12 months, and had at least 1 ambulatory visit note available in the previous 12 months. We excluded patients who had been invited to participate in focus groups or other surveys related to OpenNotes within the preceding 12 months. Using portal tracking data, we identified patients who had, and had not, accessed available visit notes in the previous 12 months and described them as readers and nonreaders, respectively. We did not exclude nonreaders because we wanted to gain some understanding of why they had not read the notes. BIDMC and UW included all eligible readers and a random sample of eligible nonreaders in the survey sample. For administrative reasons, Geisinger drew random samples from both groups, resulting in smaller samples than the other 2 sites. Across the 3 sites, 109,904 readers and 27,959 nonreaders were sent invitations for the survey. The Institutional Review Boards at BIDMC, Geisinger, and UW approved the survey and study protocol at their respective sites.

Constructing the Questionnaire

This survey draws heavily on questions used in the original demonstration project in primary care; its development has been previously described []. We updated the questionnaire based on comments from outside reviewers, focus groups with diverse patients from a community health center, assessment of the distribution of responses in the original study, and an evaluation of psychometric properties of different versions of some of the items, including those related to benefits and risks of reading notes (manuscript under review). Except for a few site-specific modifications, the questionnaire was the same for all patients, and with the exception of skip patterns, free text, and demographic questions, all items required a response. Both the original and updated versions are available on request from the authors.

Conducting the Survey

We surveyed patients between June and October 2017, using a Web-based survey platform, Survey Gizmo. Patients were sent invitations by email either to their portal accounts or to the personal email address associated with the accounts. Each patient's invitation contained his or her study identification embedded in a unique link to the survey, and each study identification could be used only once. Following the original invitation, patients received 2 reminders 1 week apart if they had not completed the survey. Knowing that patients sometimes confuse notes with other parts of the medical record, or with the portal itself, we described clinical notes in both the survey invitation and in a survey question and we also showed a screenshot of the location of visit notes on their institutions' portals to increase the likelihood that patients would report on visit notes. Knowing also that invitations might be opened by care partners rather than patients, each respondent had an option to complete the survey as a patient or as a care partner, and care partners were automatically linked to a different questionnaire. We offered respondents an incentive for completing the survey: a raffle of 50 prizes of US $25 or US $50 at each site.

Statistical Analysis

To maximize the chances that we were including responses about clinical notes rather than another part of the record, as a final step, we excluded responses from patients whose self-report of note reading in the past 12 months did not match portal data; for example, patients reported they had read notes, but the portal tracking data showed they had not. We also excluded respondents who reported reading notes for a week or less, or did not answer the question about length of time reading notes, since our objective was to assess patients' experiences over the prior 12 months. Except as noted in the tables, all questions included in this analysis had < 4% missing responses, and denominators include all nonmissing responses to each item. Items related to medication management are addressed in another paper [].

Most items addressing potential benefits and risks asked for ratings on an 11-point scale, ranging from 0 (not at all important, confusing, or concerned) to 10 (extremely important, confusing, or concerned). Responses to these items were collapsed into 4 categories a priori for analysis: 0-1, 2-4, 5-7, and 8-10, and we reported the 8-10 category as very important, confused, or concerned. Four-level agreement responses were dichotomized as agree or somewhat agree, and disagree or somewhat disagree.

Using percentages and chi-square tests, we compared respondents with nonrespondents using administrative data available at each institution: age and sex at all 3 sites, Hispanic ethnicity at Geisinger and UW, and insurance type at BIDMC and Geisinger.

We used descriptive statistics to examine respondents' sociodemographic and health characteristics and experiences with note reading, both overall and stratified by study site. We used the chi-square test for independence (degrees of freedom: row-1 × column-1) to test for differences according to demographic characteristics in patients' experiences in note reading. We performed a multivariable analysis using log Poisson regression models to estimate overall relative risks and 95% CIs for reporting benefits as very important according to patient characteristics, adjusted for other sociodemographic and health characteristics and number of notes read. Owing to the large sample size, we expected even slight differences between groups to be statistically significant. Therefore, we interpreted intercategory differences in proportions or relative risks of 10% or more as meaningful differences. All analyses were completed using SAS software version 9.4 (SAS Institute Inc).

Results

Participants

Of 136,815 patients who received survey invitations, 21.68% (29,656/136,815) responded; 28,782 were patients, and 874 were care partners (). Compared with nonrespondents, respondents were older at all 3 sites. At BIDMC and UW, white patients were more likely to respond than nonwhite patients. No differences were noted between responders and nonresponders regarding sex at any of the 3 sites, regarding Hispanic ethnicity at UW and Geisinger, and regarding insurance type at BIDMC and Geisinger (data not shown).

Of the 28,782 patient respondents, 62.82% (18,081/28,782) were female; 72.90% (20,982/28,782) were aged 45 years or older; 76.94% (22,146/28,782) were white; 53.06% (15,271/28,782) were employed; and 14.30% (4115/28,782) reported fair or poor general health. Overall, 64.92% (18,685/28,782) had completed college, but the sites differed substantially: the proportion of those with a high school education or less was 4.8% (655/13,613) at BIDMC and 5.4% (708/13,119) at UW, but 25.9% (530/2050) at Geisinger.

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Figure 1. Study flow diagram. BIDMC: Beth Israel Deaconess Medical Center; UW: University of Washington Medicine.
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Accessing and Reading Notes

After note reading exclusions, 23,710 responses were included in the analysis: 22,947 note readers and 763 nonreaders. Among note readers, three-quarters reported reading notes for a year or more and half reported reading 4 or more notes. In general, they reported locating notes easily on the portals and considered email notifications about new notes useful. About one-third of readers at BIDMC (4065/11,899, 34.16%) and UW (2998/9719, 30.85%), but only 20.1% (237/1178) at Geisinger, reported mentioning to their clinicians that they had read a note, and about the same proportion (7324/22,798, 32.13%) said they were encouraged by their clinicians to read notes. Among those who were encouraged, 60% read 4 or more notes compared with 46% of those who were not encouraged to read notes. In total, 37.74% (8588/22,753) reported sharing or discussing a note with a family member or someone else. Overall, 98.46% (22,593/22,947) of readers thought making notes available to patients a good idea, and 62.38% (13,427/21,525) said access to visit notes would be very important in choosing a future provider.

Benefits and Risks of Note Reading

As shown in , between 50.43% (11,346/22,514) and 72.62% (16,354/22,520) of patients in all sites combined rated note reading as very important for helping them achieve 6 different benefits. In contrast, 3.3% (737/22,304) said they were very confused by their notes, 4.83% (1078/22,303) reported being more worried after reading notes, and 11.46% (2529/22,067) reported being very concerned about privacy. The positive perceptions of benefits were evident across the 3 sites, with patients in rural Pennsylvania reporting the highest ratings of importance of note reading.

We found meaningful differences (≥ 10%) in patients' perceptions of the benefits of reading notes according to sociodemographic characteristics (). Black patients were more likely than white patients to rate note reading as very important for 5 of the 6 benefits and patients aged 45 years or older rated it very important for 4 of the benefits compared with those aged 18 to 24 years. Those who usually spoke a language other than English at home were more likely than English speakers to use notes to make the most of visits, remember the plan of care, and prepare for visits. Patients with the fewest years of education and Hispanic patients were more likely than others to cite note reading as very important for remembering the care plan and preparing for visits. Patients who read a greater number of notes were more likely to cite reading notes as very important for all 6 benefits.

Few patients reported being very confused or more worried from reading notes, with only minor differences according to sociodemographic characteristics (). Though differences did not reach the 10% threshold, greater proportions of black patients, Asians, and other minorities reported being very concerned about privacy related to open notes, 16.2% (174/1076) to 19.2% (104/543), compared with 10.15% (1828/18,012) of white patients.

After adjusting for other factors, education level continued to be inversely associated with patient ratings of the importance of note reading for all 6 benefits (). Similarly, after adjusting for other characteristics, black patients were more likely than white patients to rate note reading as very important for achieving benefits. Older patients-especially those aged > 45 years-were more likely to rate notes as important for 4 of the benefits. Hispanic patients and those who spoke a language other than English at home found notes very important for 3 benefits. Notably, the importance of note reading in preparing for office visits was the benefit most endorsed among more vulnerable demographic groups.

When we asked the 763 nonreaders about the main reason they had not looked at visit notes, about half selected, I forgot or did not know my visit notes were available. A total of 10.4% (79/761) indicated they did not know they had a right to look at notes, 8.8% (67/761) were too busy, 7.2% (55/761) did not think reading would be useful, and 6.3% (48/761) were not able to find the notes. Among the 12.0% (95/761) reporting another reason, the majority wrote that they had no need to read notes because they trusted their clinicians, had received printed copies, or had no health issues or recent visits. Only 9.1% (69/760) of nonreaders reported being encouraged by a clinician to read their notes. We found no material differences in demographic characteristics in the nonreaders compared with the readers (data not shown). Even though they had not read notes, 89.0% (679/763) of nonreaders agreed that making notes available to patients on the Web is a good idea.

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Figure 2. Benefits and risks of reading notes. BIDMC: Beth Israel Deaconess Medical Center; UW: University of Washington Medicine.
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Table 1. Proportion of patients identifying notes as extremely important in achieving benefits.
View this table

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Table 2. Proportions of patients reporting risks from reading notes.
View this table

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Table 3. Adjusted relative risk and 95% CI of identifying notes as very important for potential benefits.
View this table

Discussion

Principal Findings

In this study, the largest assessment to date of patients who read a wide variety of clinicians' notes over time, patients report that reading clinical notes brings them substantial benefit. The respondents represent urban and rural settings, varying education levels, and broad age and racial distributions, and they had access to notes composed by most clinicians providing primary care and ambulatory care in medical, surgical, and mental health specialties. About two-thirds of patients describe notes as extremely important in increasing their sense of control, improving recall and understanding of their plans for care, and better preparing them for visits. Few reported confusion or increased worries, and those patients from medically underserved groups reported the most benefit. Whether or not they chose to review their notes, patients overwhelmingly approved the practice, with a majority reporting that access to notes would be extremely important in determining their future choice of clinicians. On the contrary, only a third of patients recalled discussing their notes during visits or having their clinicians recommend that they read them.

Comparison With Other Studies

These reports from almost 23,000 patients who read their notes amplify and reinforce the findings from smaller, more targeted, and shorter studies within primary care practices and discrete clinical specialties [-,,,,]. Many respondents had read notes over several years, and these results may foretell a steady state of patient experiences over the longer term. The high proportion of patients reporting benefits from reading notes did not diminish compared with our first survey in primary care patients several years ago, and more patients reported mentioning their note reading to their providers (32%, up from 19%) [].

Implications of the Findings

Focusing on clinically important process measures, these results strongly suggest that transparency helps patients feel more engaged in their care. This is an important finding, given that a growing body of evidence indicates that engaged patients are more likely to adhere to treatment plans and medications, follow through on screening and prevention protocols, detect and prevent errors, and adopt more effective management strategies for chronic illnesses [-].

Although the time-honored principle of patient-clinician confidentiality is not in itself affected by open notes, it is up to patients to decide whether or not to disclose their medical information to others. More than a third of respondents reported sharing notes with someone else, almost twice the rate reported in 2012 in the study of primary care patients in the same institutions []. Shared notes may be particularly helpful to informal care partners [,] and to those in search of informal second opinions from both lay and professional associates.

In this survey, patients who are potentially the most vulnerable-those who are older, less educated, non-white, Hispanic, or not English speakers at home-reported the most benefit. By virtue, both of taking the initiative to sign onto a patient portal and reading their notes, they may not be representative of other Americans with similar demographics, as is true for everyone in our sample. But this finding extends and amplifies findings in earlier inquiries [-,,,,,]. Vulnerable patients may come to a visit with a lower baseline sense of control and knowledge than others; they may also have more difficulty understanding or retaining what practitioners say or emphasize. Assisted at times by family members or other acquaintances who can help interpret and research points made in notes, the possibility of review in their homes may contribute to their particular enthusiasm for this new opportunity. Moreover, in several studies, patients who are disadvantaged may trust their health professionals less than those with social and educational backgrounds similar to their clinicians []. Shared notes can increase trust, as studies and anecdotes from both patients and clinicians suggest [,]. That particularly vulnerable patients may gain the most from open notes is worthy of further inquiry. Similarly, the fact that minority patients are more concerned about privacy than white patients also deserves further study.

As some of our findings suggest, embedding open notes into clinical practice faces many challenges. Even in these 3 mature institutions, the majority of their patients have not registered on their patient portals, and half of the responding nonreaders did not know that notes were available-even though they were using their portals for other purposes. Moreover, contrary to our predictions, interchange in the clinician's office about past notes was infrequent. Here, there were also substantial differences across the sites. Patients from rural Pennsylvania were less likely than those in Boston and Seattle to report speaking with their providers about note reading. However, they were also more likely to report benefits from reading, including greater feelings of control of their care and better preparation for office visits. Access to clinicians' notes may offer particular benefits to rural populations, a possibility that warrants further study.

Strengths and Limitations

This is a cross-sectional study examining patients' self-reported experiences from only 3 regions of the United States, and results may not be generalizable to other regions or practices. Moreover, the response rate was modest, although it was similar to the response rate in a recent Consumer Assessment of Healthcare Provider and Systems survey []. It is possible that the survey respondents were those most enthusiastic about open notes. Although there were some demographic differences between responders and nonresponders, these differences were small, and the size of the sample analyzed gives further weight to the findings. It should be noted also that the majority of respondents were white, in good health, and highly educated. It is difficult to draw firm conclusions about the benefits to non-English speakers because the survey was only offered in English; subsequent surveys could be administered in other languages and also explore issues of health literacy. Finally, the literature on the impact of portals on patients is often confused by lack of specificity about different functionalities. A strength of our study is that we took several steps to make sure patients had experience reading notes and were reporting on reading visit notes, rather than on other information available on their portals.

Unanswered Questions and Future Directions

Some argue today that fully open medical records are simply ...the right thing to do, and this large survey of patients furnishes further evidence that their benefits outweigh their risks, certainly from the point of view of patients. Although the findings confirm that the benefits of note reading extend beyond primary care practices to virtually all specialties and types of clinicians, more needs to be learned about using open notes as a tool for communication and promoting interaction between patients and clinicians across health care venues and populations. The Department of Health and Human Services has proposed new rules that would increase patient access and control of their medical information, and easy electronic access to notes could become the law of the land []. To what degree can active educational interventions help patients learn optimally from what their records document? And in the future, might patients also contribute to their records by providing interval histories and articulating their goals for a visit in their own words, thereby enriching narratives, promoting focused interactions, and hopefully off-loading work from beleaguered clinicians? [].

At a time when medical practice in the United States is moving toward shared notes as a new standard, the patients participating in this study offer both affirmative and provocative reports, but building shared notes into the fabric of care remains a work in progress.

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

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Original Paper 1 Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States 2 Harvard Medical School, Boston, MA, United States 3 College of Nursing and Health Sciences, University of Massachusetts, Boston, MA, United States 4 David Geffen School of Medicine, University of California Los Angeles, Los

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This article discusses several barriers to telemedicine implementation (patient preference, technological infrastructure, language barriers, complex care, etc). As FNPs, we can potentially mitigate these barriers to continue to promote increased access to care, equitable delivery, and lower costs).

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If the address matches an existing account you will receive an email with instructions to reset your password.

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UMass Memorial Health Care (UMass) and Milford Regional Medical Center (MRMC) launched their connection to the Massachusetts Health Information Highway (Mass HIway) in May when MRMC began sending patient lab results electronically to UMass, an achievement that represents a significant step forward for secure and efficient transfer of patient information in Massachusetts and better overall care outcomes.

The electronic health information exchange (HIE) between the two providers stems from the HIway Implementation Grant program the Massachusetts eHealth Institute (MeHI) launched in 2013. The initiative awarded $2.3 million to 32-grantees representing 80 health care organizations across the Commonwealth. The collaboration between the five-hospital UMass and the 145-bed MRMC was among the proposals selected for the grant program and one of the first to go "live."

"There has been a long-term interest in getting Milford Regional Medical Center information into the UMass world," said Mark Taricco, manager of integration at UMass. "When the grant opportunity came up we took advantage of it to bring Milford lab results into the UMass realm."

Through the grant program, Umass worked with MRMC to establish an HL7 interface on the HIway that connects the two provider organizations. Patient lab results generated at MRMC travel via the HIway to UMass and are automatically entered into the hospital system's dbMotion platform, a data aggregating tool that pulls together patient history from various electronic systems.

Under the recently completed connection, patient information flows in one direction - from MRMC to UMass. Taricco said future updates to dbMotion will allow information to travel in the other direction, from UMass to MRMC as well as to other providers.

The previous system for sharing patient lab information between MRMC and UMass required transporting actual paper documents and using fax machines. The lab result information had to be typed into the UMass system manually, which raised the chances for input errors, missing information and duplicate testing.

"When you're manually typing in information, mistakes can be made very easily, such as typos and incorrect results," said Taricco. "Other issues include timing and delays in getting that information typed into the system, whereas electronically we can get information sent directly to us and automatically entered into dbMotion."

The electronic sharing of patient lab results between UMass and MRMC is a first step on the HIway for the two providers, but Taricco said the connection will become more valuable and when it expands to include other types of information, such as radiology tests.

Additionally, UMass plans to seek out HIE connections with other organizations and hospitals.

"Once there is a larger variety of systems participating, we'll be able to take advantage of not performing redundant tests and things of that nature because we'll have a broader scope of the patient history," said Taricco.

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UMass Memorial Health Care, Milford Regional Medical Center Connect to Mass HIway to Share Lab Results

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UMass Memorial Health Care (UMass) and Milford Regional Medical Center (MRMC) launched their connection to the Massachusetts Health Information Highway (Mass HIway) in May when MRMC began sending patient lab results electronically to UMass, an achievement that represents a significant step forward for secure and efficient transfer of patient information in Massachusetts and better overall care outcomes.

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Allows for enhanced safety, efficiency, improved delivery of care for patients in MA.

From Week 7 Content

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Relying on paper charts, phone calls and fax machines to send and receive patient health information between care providers is unreliable and time-consuming and often leaves providers with an incomplete picture of their patients' medical history. This wastes time and resources and can lead to medical errors. These old methods of communication are rapidly being replaced by Health Information Exchange (HIE). Using nationally recognized communication protocols and safety standards, HIE is the secure electronic transfer of Protected Health Information (PHI) among organizations.

HIE allows doctors, nurses, pharmacists and other providers to share patient information in a secure, timely and efficient manner. This enables them to collaborate and consider their patients' full medical history, medications, and other data to make informed decisions, improve diagnosis, avoid duplicative testing, and reduce medical errors and re-admissions. The electronic exchange of actionable information improves the quality, safety and efficiency of health care.

There are three progressive levels of HIE implementations:
1. To coordinate care,
Directed Exchange enables providers to send and receive secure information electronically. 2. For unplanned care,
3. F Query-based Exchange adds capabilities to find or request information from other providers. or patient control, Consumer-Mediated Exchange allows patients to aggregate and control their health information.

The HIE capabilities are typically provided by organizations specialized in networking technology. The organizations design and support the infrastructure needed to securely transfer clinical information between the multiple disparate Electronic Health Record ( EHR) systems used in a provider network.

Besides available commercial solutions, many U.S. states provide HIE alternatives on a statewide level to support the Meaningful Use requirements. In the Commonwealth, the Mass HIway, is the statewide HIE .

Information on the nationwide Health Information Exchange strategy, including the alternatives, capabilities and advantages of HIE can be found on HealthIT.gov.

The HIE Toolkit provides tools and use case examples for guiding an organization through the HIE process.

The searchable HIway Connections Map lists all organizations connected to the Mass HIway, either directly or via a HIway Trusted HISP

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Relying on paper charts, phone calls and fax machines to send and receive patient health information between care providers is unreliable and time-consuming and often leaves providers with an incomplete picture of their patients' medical history. This wastes time and resources and can lead to medical errors.

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From Week 4 Content

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With Human Dx, in five minutes, any member of the medical community can collaborate on clinical cases from around the world. This enables contributors to:

Access the collective insights of colleagues and the medical community on complex clinical cases.

Accelerate personalized learning and clinical reasoning in many different fields of medicine, using rapid case simulation and feedback.

Store, modify, and share anonymized cases seen in the field, for personal reference and professional use.

Satisfy education and ongoing medical licensing requirements.

Garner broader recognition within the medical community for problem solving capabilities and topical knowledge.

The following brief tutorial videos demonstrate these use cases.

1. Global Morning Report tutorial

Every morning, solve the best cases from around the world to enhance your clinical reasoning and help patients and doctors everywhere. To learn more, please visit www.humandx.org/gmr.

2. Collaborating on a case: iPhone tutorial

This video demonstrates how to use Human Dx to collaborate on clinical cases on the iPhone.

3. Collaborating on a case: web tutorial

This video demonstrates how to use Human Dx to collaborate on clinical cases on the web.

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With Human Dx, in five minutes, any member of the medical community can collaborate on clinical cases from around the world. This enables contributors to: Access the collective insights of colleagues and the medical community on complex clinical cases. Accelerate personalized learning and clinical reasoning in many different fields of medicine, using rapid case simulation and feedback.

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The convergence of technology in healthcare is becoming a reality. In the next few years, technologies will completely change the landscape of care. Here are our predictions for the next 5 years of convergent health.

AI and machine learning will change how hospitals make every decision

Often, we think of AI in healthcare terms of how it will impact patients, through device technology or perhaps population health. But more and more, we see hospitals and healthcare facilities using AI tools, not only to track patients but to run their businesses more efficiently.

Forbes predicts that AI for healthcare IT Application will cross $1.7 billion by 2019. And a significant part of that prediction is for hospital workflows, e.g., HR management, supply stocking, and productivity tracking. In addition, Forbes says to look for AI to influence imaging diagnostics, drug discovery, and risk analytics applications.

Deloitte's Hospital of the Future report says that AI will help simplify the admission, discharge, and other processes to improve efficiency and patient satisfaction. For example, if a patient's physician advises admission, instead of the patient registration process, the patient would receive a digital welcome packet. Clinical, financial, and demographic information would be automatically filled out through cloud records. Likewise, non-medical support and discharge workflow could be managed and tailored to a patient's needs.

HIMSS examination of the top trends of 2019predicts a broader adoption of AI and machine learning for population health. It notes that the technology will identify patients at risk and deliver personalized (precision) treatments.

The Forbes article also notes that pricing concerns for implementing AI into Hospital IT will force suppliers to provide clear ROI evidence and work to become more cost-effective to sustain the market growth.

Digital therapies will enhance or replace traditional treatments, and further decentralize healthcare

We are already seeing increased use of digital products to compliment health practices, e.g., medication compliance. Experts also see a rise in digital technologies used as alternatives to traditional treatments, such as prevention and management programs for diabetes and other chronic conditions.

Forbes predicts that digital health tech for use outside the hospital will grow by 30% and cross $25 billion before the end of 2019. Tools such as remote patient monitors, telehealth platforms, personal emergency response devices, and other mHealth applications will continue to gain popularity. Provided these innovations support the capture and delivery of clinically relevant data that demonstrate improved health outcomes, they will be encouraged by favorable reimbursement policies.

Patients will start to accept virtual healthcare

Accenture's Digital Health Technology Vision 2019 notes that virtual reality or extended reality (XR) systems are increasingly being used in healthcare. The report notes that 38% of healthcare organizations have adopted XR.

Brian Kalis, Accenture's managing director of digital health writes that extended reality enables machines to behave with natural mannerisms, making the experiences immersive. For example, Cedars-Sinai is using XR for pain management. The system uses XR to help patients cope with pain through breathing techniques and positive thinking. The hospital reported that patients experienced a 24% pain reduction after 10 minutes.

In addition, XR has a significant opportunity to help make telehealth the first line of connection for patients. Steve Burrill, Vice Chairman, US Health Care Leader, Deloitte LLP wrote in an advertorial for Modern Healthcare that virtual health could help patients who might otherwise avoid the doctor until a problem worsens communicate more readily with caregivers.

He noted that despite the possible benefits, only a small percentage (14%) of physicians are using such technology, likely because of a lack of infrastructure and reimbursement. Among insurers, however, as of 2016, 74% of large employer-sponsored health plans had incorporated telehealth into their benefits.

Conclusion

The future of healthcare is closer than we might think. As we near the next decade, the challenges of reducing costs, increasing access to care, and improving outcomes remain. But converging technology is changing the conversation. Digital health, virtual reality, AI, and machine learning are allowing designers and developers to dream of a new healthcare experience. Healthcare that meets patients where they are, that unlocks data to provide health at a personal level on a universal scale. That's a future worth encouraging

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Future Health: Three Healthcare Technology Predictions - Product Creation Studio

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The convergence of technology in healthcare is becoming a reality. In the next few years, technologies will completely change the landscape of care. Here are our predictions for the next 5 years of convergent health. Often, we think of AI in healthcare terms of how it will impact patients, through device technology or perhaps population health.

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Why do we need informatics? Week 3 Key Takeaways

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Why do we need informatics? Week 3 Key Takeaways

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HIT competencies are needed to:
*communicate & manage knowledge
*mitigate errors
*support decision-making competencies

Informatics utilization is essential:
*ensures safe pt care
*valuable databases focusing on
-terminologies and data
-providing effective pt care

NPs must address:
*knowledge
*skills
*attitudes

Outlined by QSEN & IOM

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At 1:28 in the TIGER video, Michelle mentions that in the 2004 meeting pertaining to the federal framework for health information technology, nursing was not included. I am curious why nursing had not yet been included previously? What reasoning or rationale was there for not including the field of nursing? Were there barriers?

At 18:34, Michelle mentions many programs are moving away from having informatics as one specific course and instead embedding it into all courses throughout the curriculum. I am wondering if Simmons will someday follow suit, or if having the one course has proven to be more beneficial at this time.

https://2sn.onlinenursing.simmons.edu/ap/courses/961/sections/99c785e5-7847-433e-977d-486b6d5509a7/coursework/module/19cf4a11-e89d-4b12-b7ad-62be5516b918/segment/5b82a0aa-6568-403a-ba60-f6ac58083c47

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The National Library of Medicine (NLM) Resource for NPs

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The National Library of Medicine (NLM) Resource for NPs

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The NLM clinical queries tool provides practitioners with diverse knowledge and opportunities for implementing evidence-based interventions among their practice. The clinical queries tool may prevent invasive therapies through the trialing of first-line or alternative therapies prior to the implementation of more aggressive interventions.

https://pubmed.ncbi.nlm.nih.gov/clinical

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An astute NP efficiently uses electronic medical records to facilitate a seamless transition of care between providers who may not share the same physical office, assuring the delivery of quality and safe care. Nurse practitioners possess up-to-date training on how to utilize electronic prescribing services and telehealth, to ensure patients and their families receive all necessary services as conveniently as possible to allow for the best possible outcomes.

AANP Forum. (2017). The importance of HIT. The Journal for Nurse Practitioners. https://www.npjournal.org/article/S1555-4155(16)30746-2/fulltext