An OpenNotes study found that letting patients type pre-visit agendas into the electronic health records system before seeing the physician made appointments more efficient and improved communication.
Joann Elmore, MD, MPH, professor of medicine at the University of Washington School of Medicine, is a slow typist. So slow that one of her patients grabbed the keyboard away from her while she was entering the patient's information into the electronic health record.
"Come on doc, let me type," the patient said. She and asked her Elmore what she should write. Elmore told her she should decide. It was about her, after all.
That simple idea of letting a patient contribute to the medical record in their own words is the central focus of a new study published in the Annals of Family Medicine.
Elmore is the study's lead author and research director for OpenNotes, a national movement that for more than four decades has encouraged physicians to share medical records with their patients.
In what they say is the first OpenNotes study of cogeneration of clinic notes, Elmore and her team of researchers wanted to understand the effects of having patients generate a portion of their own medical records.
They found that letting 101 patients type in pre-visit agendas before a doctor's appointment improved self-reported communication and efficiency.
The patients, all of Harborview Medical Center Adult Medicine Clinic in Seattle, WA, a safety-net facility, contributed to their notes and participated in a post-visit survey.
From June 9 and July 22, 2015, patients were either recruited via telephone the night before their appointments and asked to arrive 30 minutes early, or were approached by a receptionist if they arrived early enough.
A research assistant, third-year medical student McHale Anderson, who is also the paper's lead author, "met patients in the waiting room, provided them with a laptop computer with the clinic's [EHR/EMR] interface, and let them type their agenda," which became part of the permanent visit record, according to the study.
The Patient's Voice is in the Chart
Their 28 clinicians reviewed the patient-entered notes either before or when they entered the patient exam room and completed post-visit surveys.
"Reading the patient's voice in the chart can really guide how a physician enters a room," Anderson says.
"It can really guide and facilitate a really good relationship." He points to one instance where the clinician read how upset the patient was about having to wait for so long and being passed from doctor to doctor.
"They had a beautiful conversation in the waiting room," Anderson recalls, and the patient felt better. (Anderson did not include this data point in the study because he had intervened.)
In addition to asking about demographic characteristics and self-reported health, the patients were surveyed about their perceptions of the experience, using a 5-point Likert scale (strongly disagree, disagree, neutral, agree, strongly agree).
Clinician surveys asked whether the agendas gave them an improved understanding of the patient's health concerns and were helpful, as well as information about their age, sex, role in clinic, and perceptions of the agendas. (See the survey here).
More Efficient Visits
Participants were very positive about the experience, including clinicians who were skeptical at first.
"Understandably, the doctors in our busy, busy clinic are swamped, and they weren't thrilled with the idea," says Elmore. "In the end the doctors loved it, and they didn't want it to go away."
According to the surveys, patients and clinicians agreed or strongly agreed with the following statements in regard to the patients' self-entered notes:
- Made the clinicians more prepared (78% of providers, 82% of patients)
- Improved clinician understanding of patient concerns (74% of providers, 75% of patients)
- Made the visit more efficient (63% of providers, 79% of patients)
- Helped prioritize the visit (82% of providers, 84% of patients)
- Improved patient clinician communication (74% of providers, 79% of patients)
- Want to use patient agendas in the future (82% of providers, 73% of patients)
One patient wrote, "Gave my doctor my information so I wouldn't be nervous and forget." Another wrote, "Doctor and I on the same page."
The physicians provided comments such as, "Got time to think about issues ahead of time" and, "Engaged patient to participate more in the visit; he felt heard."
"The value of reading something in someone's writing can give you an idea of how they're really feeling," Anderson says. The experience made him realize "how valuable that can be to building a patient-physician relationship."
In addition to gathering data about patient and clinician perceptions of the project, Anderson also tallied how much time patients spent typing the agendas and the number of words they typed.
He found that agendas were generally brief; 83% of patients typed for less than 10 minutes, and 80% typed less than 60 words.
Although the study didn't collect data about costs or length of the visits, Elmore says she could see such an initiative saving money, and not only by making visits more efficient.
If physicians truly addressed all of the patients' questions and concerns adequately during a clinic visit, the patient could be less likely to return to the clinic or wind up in the emergency room.
Limiting Factors to the Study
She suggests participating hospitals, clinics, and health systems could have a leg up in another way, too. "It's a competitive market… patients will actively seek out a health system that offers this," Elmore says.
Despite the study's promise, the authors acknowledged several limiting factors:
- The study was conducted at a single clinic with no comparison group
- Financial incentives were provided to participants (gift cards)
- A research assistant facilitated the agenda typing process
- The study included a vulnerable patient population. Of those invited to participate, 12% declined and 26% were not eligible because they could not type or write in English.
Despite these limitations, the authors note that patient navigators, peer coaches, translators, or audio and touch-screen technologies may be able to address limitations in English or computer literacy, or low vision, hearing, or comprehension.
"Even in a safety net hospital, it really can work," Anderson says.
Elmore says she can see this becoming part of patient visits in the future, perhaps with automatic emails that patients get before their appointment, and pre-clinic agendas and data fields that are modified depending on the clinic.
Such steps forward would rely heavily on technology vendors. "We need the vendors of EHRs to make this streamlined and easy," Elmore says. "I want the vendors to make this part of the existing patient portals."
Doing so would only help deepen the patient-physician relationship, says Elmore.
Alexandra Wilson Pecci is an editor for HealthLeaders.
