How To Write A Note Online

Transcription

1 Patient Access to Clinical Notes in the Electronic Medical Record - Provider Attitudes and Concerns Anupam Chandra, Karen Ytterberg, Sidna M Tulledge-Scheitel, Frederick North MED E TEL April 9-11, MFMER slide-1

2 Background March Mayo Clinic allowed patients online access to all their clinical notes going back to 2007 Goal Transparency Improve self management Improve safety Shared decision making 2014 MFMER slide-2

3 Hope 2014 MFMER slide-3

4 Concern 2014 MFMER slide-4

5 Aim To understand providers attitudes and concerns about granting patients online access to their clinical notes 2014 MFMER slide-5

6 Method survey (REDCap ) of 352 primary care providers - Internal medicine, Family medicine and Pediatrics Included: MDs, Physicians in training, NPs & PAs Comparative analysis of provider responses before & 5 months after implementation of allowing patients access to their clinical notes online 2014 MFMER slide-6

7 Survey Details 11 Questions - Anticipated/Experienced Current practice for creating notes Provider initiated changes (multiple answers) Clinical content Differential diagnoses transcription process Single answer multiple choice questions with 5 levels Patient requests to change content Patient requests for additional information Patient safety Patient self-management Patient understanding of medical information Plan to make a dedicated area in note for instructions for patient One visual analog scale to capture anticipated/experienced changes in effective communication with other providers 2 areas for free text comments on anticipated/experienced changes to content and benefits and hazards 2014 MFMER slide-7

8 Results 352 primary care providers were surveyed 197 responded to pre implementation survey 160 responded to post implementation survey 120 were responded to both and were analyzed as matched pairs Statistical analysis using JMP 9.01(SAS Institute, Cary, NC) 2014 MFMER slide-8

9 Provider Comments on Changes in Content of Clinical Note - Implementation This is a terrible idea More circumspect, likely will be less helpful to other clinicians Less likely to use words like "obese", "unkempt None Concern that patient's will be upset by mentioning any psychosocial concerns in the note 2014 MFMER slide-9

10 Provider Comments on Anticipated Benefits & Hazards Implementation This is a terrible idea. The last thing we need is having patients us through the portal to ask that we change a line they disagree with in the note. I see this being a huge burden in the future. I believe the benefits of this far outweigh its drawbacks I do however disagree with the patient having access before the note is finalized since typos and inaccurate information sometimes is transcribed. Benefit: if the patient has forgotten discharge instructions they can access them for review. Hazard: medical record becomes less helpful for providers sharing patient care responsibilities as providers may not feel comfortable documenting information that might potentially "upset" a patient. This is particularly worrisome in documenting histories/social situations for patients being treated for mood disorders. This is a terrible idea. I anticipate this making my documentation a less effective form of communication to other staff and as a reminder to myself. For example, at times I discuss a broad differential in my IRP as a reminder of what to consider if my top differential is incorrect. While I would be happy to discuss my differential and why I'm not pursuing tests etc, I don't have hour long appointments with each of my patients. I also suspect this will motivate patients to ask even more for tests/procedures/consults that they don't need because they searched on-line and somewhere someone said they should do x. This is a terrible idea. Patients benefit by being able to refer to written documentation rather than relying primarily on memory of what doctor told them MFMER slide-10

11 Provider Responses to Changes in Content Survey Question n(%) n(%) P-value Matched n(%) Matched n(%) Count 197 (100%) 160(100%) 120(100%) 120(100%) P-value Change in candidness 126 (64%) 71(44%) * 77(64%) 52(43%) * Fewer abbreviations 25(13%) 7(4%) * 15(12.5%) 6(5%) Decrease jargon 11(6%) 4(2%) (8%) 3(2.5%) Other 6(3%) 3 (1.8%) (1.6%) 2( 1.6%) No change 57(29%) 83(52%) <0.0001* 37(31%) 64(53%) * 2014 MFMER slide-11

12 Provider Responses to Changes in Content Matched MFMER slide-12

13 Provider Responses to Changes in Differential Diagnoses Survey Question P value Matched Matched P value Count 197 (100%) 160(100%) 120(100%) 120(100%) Avoid Sensitive Diagnoses 57(29%) 23(14%) * 33 (28%) 16 (13%) * Avoid Anxiety Provoking Diagnoses 57(29%) 24(15%) * 31 (26%) 19 (16%) Other 6(3%) 6(4%) (0.8%) 3 (2.5%) No change 122(62%) 120(75%) * 78 (65%) 92 (77%) MFMER slide-13

14 Provider Responses to Changes in Differential Diagnoses Matched Sensitive D Anxiety D Other No Change 0 Sensitive D Anxiety D Other No Change 2014 MFMER slide-14

15 Provider Responses to Changes in Transcription Process Survey Question n(%) n(%) p-value Matched n(%) Matched n(%) p-value Count 197 (100%) 160(100%) 120(100%) 120(100%) Increased length of time Proof reading Grammar 65(33%) 19 (12%) <0.0001* 39(33%) 12 (10%) <0.0001* 68(35%) 28 (18%) * 34(28%) 17(14%) * Proof reading 111(56%) 46(29%) <0.0001* 63(53%) 33(28%) * Content Other 5(2.5%) 2(1%) (2.5%) 1(0.8%) No change 66(34%) 106(66%) <0.0001* 46(38%) 82(68%) <0.0001* 2014 MFMER slide-15

16 Provider Responses to Changes in Transcription Process Matched Duration Grammar Content Other No Change 0 Duration Grammar Content Other No Change 2014 MFMER slide-16

17 New Section on Instructions for Patients P value Matched Matched P-value 51(26%) 9(6%) <0.0001* 28(23%) 8(7%) * Mean (Visual Analog) Matched Matched MFMER slide-17

18 Patient Requests to Change Content Response Matched Matched Count 197 (100%) 160(100%) 120(100%) 120(100%) Major Decrease 1 0 1(1%) 0 Minor Decrease No Change 15(8%) 95 (59%) 9(8%) 73(61%) Minor Increase 124(63) 56(35%) 73(61%) 39(33%) Major Increase 57(29%) 9(6%) 37(31%) 8(7%) 2014 MFMER slide-18

19 Patient Requests to Change Content % p value<0.0001* Matched% p value <0.0001* MFMER slide-19

20 Patient Requests for Additional Information Response Matched Matched Count 197 (100%) 160(100%) 120(100%) 120(100%) Major Decrease Minor Decrease 3(2%) 1 3(3%) 1 No Change 28(14%) 108(66%) 17(14%) 80(67%) Minor Increase 115(58%) 46(29%) 69(56%) 34(28%) Major Increase 50(25%) 5(3%) 30(25%) 5(4%) 2014 MFMER slide-20

21 Patient Requests for Additional Information % p value <0.0001* Matched% p value <0.0001* MFMER slide-21

22 Change in Patient Safety Response Matched Matched Count 197 (100%) 160(100%) 120(100%) 120(100%) Major Decrease 4(2%) 3(2%) 2(2%) 3(3%) Minor Decrease 14(7%) 13(8%) 6(5%) 10(8%) No Change 129(65%) 125(78%) 77(64%) 90(75%) Minor Increase 40(20%) 18(11%) 27(23%) 17(14%) Major Increase 10(5%) 1(1%) 8(7%) MFMER slide-22

23 Change in Patient Safety % p value * Matched% p value * MFMER slide-23

24 Ability to Self-Manage Response Matched Matched Count 197 (100%) 160(100%) 120(100%) 120(100%) Major Decrease 0 1(1%) 0 1(1%) Minor Decrease 3(2%) 3(2%) 0 0 No Change 110(56%) 119(74%) 68(57%) 88(73%) Minor Increase 74(38%) 35(22%) 45(38%) 30(25%) Major Increase 10(5%) 2(1%) 7(6%) 1(1%) 2014 MFMER slide-24

25 Ability to Self-Manage % p value * Matched% p value * Major Minor Decrease Decrease No Change Minor Increase Major Increase 0 Major Minor Decrease Decrease No Change Minor Increase Major Increase 2014 MFMER slide-25

26 Understanding of Medical Information Response Matched Matched Major Decrease 1(1%) 2(1%) 0 1(1%) Minor Decrease 5 (3%) 9(6%) 4 (3%) 4(3%) No Change 87(44%) 118(74%) 52 (43%) 89(74%) Minor Increase 96(49%) 28(18%) 57(48%) 24(20%) Major Increase 8(4%) 3(2%) 7(6%) 2(2%) 2014 MFMER slide-26

27 Understanding of Medical Information % p value <0.0001* Matched% p value <0.0001* Major Minor Decrease Decrease No Change Minor Increase Major Increase 0 Major Minor Decrease Decrease No Change Minor Increase Major Increase 2014 MFMER slide-27

28 Results Summary Matched Group 53% made no changes to the content although 69% had anticipated it. ( 47% made changes) 77% made no changes to differential diagnoses although 35% had anticipated it. ( 23 % made changes) 68% had noted no changes to post transcription process although 62% had anticipated it.( 32% made changes) 7% had a new section on patient instructions and 23% had anticipated that they would. The hindrance to communication with other providers was less than anticipated by providers prior to the survey 2014 MFMER slide-28

29 Results Summary Matched Group 61% noted no change in patient request to change content although only 8% had anticipated that this would be the case. 40% noted (33% minor and 7% major ) increase. 67% noted no change in requests for additional information though 14% had anticipated this. 32% experienced minor or major increase 73% noted no change in patient self management and 57% had anticipated it. 26% noted mostly minor increase 74% noted no change in patient understanding, though 54% had expected an increase 75% noted no change in patient safety, 14% noted minor increase and 11% noted a decrease in patient safety 2014 MFMER slide-29

30 Providers Comments on Change in Content of Clinical Note - Implementation More time, more work. Patients review notes and have questions about wording, spelling. Unless we charge econsults or somesuch for this it will just be more stuff we do for free,later hours, less time for education, research, family None Had an 18 year old call patient affairs, asking that I delete mention that she had used marijuana once or twice when she was at her 17 year old GME. I have always been careful with what I write in the record, so this really didn't provoke change for me MFMER slide-30

31 Providers Comments on Experienced Benefits & Hazards - Implementation I have elaborated more upon the expected management, giving clues about what follow-up testing may be ordered. For procedures, I have included some detail about expected time for bleeding or healing. The problem list for a patient is generated by billing records and is visible to patients. That system labels problems differently than our documentation, and confuses patients. "You told me that my bone density did not require additional treatment, but my chart says I have 'osteopenia NOS' listed as 'active'. Which is it? Increased patient anxiety about lab values. Requesting deletion of accurate medical history including lifetime sexual partners, history of STI, drug or alcohol use. None I believe that patient online access to clinical notes is a fantastic and overdue achievement. However, to minimize confusion and also potentially relieve liability issues, I do think that notes should only be visible AFTER being finalized, not simply transcribed. There are many errors within the transcription process MFMER slide-31

32 Conclusions Provider documentation practices had changed and clerical burden had increased but providers had overestimated the magnitude Providers noted an increase in patient requests to change content and for additional information but providers had overestimated the magnitude Most providers did not note a major increase in patient safety, understanding of medical information, or ability to self-manage MFMER slide-32

33 Future Studies Patient perspective Outcomes Costs Education & Interventions 2014 MFMER slide-33

34 Find a Balance Patient-Expectations Patient-Safety & Provider satisfaction 2014 MFMER slide-34

35 Questions & Discussion 2014 MFMER slide-35