By establishing requirements for electronic interaction, the Meaningful Use program is driving the development of EHR features that enable information sharing and communication between physicians and patients. It is still too early to determine whether benefits will be realized in terms of increased efficiency, higher satisfaction, and lowered costs. While it may ultimately be good for the efficiency of the healthcare system and for patients — unless effectively integrated with clinical workflow, sharing of clinical information, encounter notes, and patient interaction can create administrative headaches for busy clinicians.
An October 2, 2012, article published in Annals of Internal Medicine by principle investigators Jan Walker, RN, MBA and Tom Delbanco, MD titled “Inviting Patients to Read Their Doctors’ Notes: A Quasi-experimental Study and a Look Ahead,” examined the interaction between primary care physicians and their patients after providing access to clinical notes via a patient portal and electronic messaging. The study involved 105 primary care physicians and 13,564 patients at three institutions: Beth Israel Deaconess Medical Center (BIDMC) in Massachusetts, Geisinger Health System (GHS) in Pennsylvania, and Harborview Medical Center (HMC) in Washington. (Dr. Michael Barr commented on an earlier article published in December 2011.)
Findings were based on patient and physician post-intervention surveys:
- 86% of patients with visit notes available opened at least one note.
- 5,391 patients who opened at least one note completed a post-intervention survey:
- 77% to 87% across the three sites reported that open notes helped them feel more in control of their care.
- 60% to 78% of those taking medications reported increased medication adherence.
- 26% to 36% had privacy concerns.
- 1% to 8% reported that the notes caused confusion, worry, or offense.
- 20% to 42% reported sharing notes with others.
- The volume of electronic messages from patients did not change.
- After the intervention:
- 0% to 5% of doctors reported longer visits or more time addressing patients’ questions outside of visits (0% to 8%).
- 3% to 36% of doctors reported changing documentation content.
- 0% to 21% reported taking more time writing notes.
What is particularly interesting is that at the end of the experimental period, 99% of patients wanted open notes to continue and no doctor elected to stop. 59% to 62% of patients believed that they should be able to add comments to a doctor’s note and one in three patients believed that they should be able to approve the notes’ contents. This was met by resistance, as 85% to 96% of doctors did not agree.
However, not all is good news. According to a November 21, 2012, study published in the Journal of the American Medical Association (JAMA), patients with online access to their electronic health records may have more emergency department and physician office visits in comparison to patients who do not have similar access. The retrospective cohort study was conducted over the period March 2005 through June 2010 at Kaiser Permanente Colorado. The study was designed to assess utilization of the health system by both users and nonusers of online access to health records before and after initiation of a patient patient portal. Researchers studied 44,321 members who signed up for the the online access system (MyHealthManager) and remained active users of the system for at least one year. MyHealthManager provides the ability for members to access their medical records, communicate with their physicians via email, and request appointments and prescription renewals online.
The authors found that contrary to the findings of this study (amongst others), which demonstrated a reduction in total office visits, “patients with online access to their medical records, including secure e-mail communication with clinicians, had a subsequent increase in use of most in-person and telephone clinical services.” The authors could not explain these findings and suggested that influences, such as the decision to sign up for online access to their electronic records, may preselect individuals who have a higher propensity to seek face-to-face care with a provider. By extrapolating their results to a small group practice, the authors suggest that “a primary care physician with 1,000 adult patients who have online access would need to provide for almost 10 more clinic visits per week and over 5.5 more telephone calls per week.”
While increased workload for care providers may not be the outcome that we are seeking by making personal health information available through patient portals and personal health records, there are clear advantages to sharing information more effectively and engaging patients electronically using EHRs and electronic messaging. However, we need to be cautious and should regularly measure the impact of new tools and processes as the unintended consequences can be costly from a time and human resources perspective.