Psychiatrists practiced in Germany where open notes have not yet been established as part of the healthcare data infrastructure. Open notes were perceived to increase transparency and patient involvement but were also believed to raise issues of stigmatization and conflicts.
Implementation
A patient-centered documentation skills curriculum for preclerkship medical students in an open notes era
We developed this session for first-year medical students within their foundational clinical skills course to place bias-free language at the forefront of how they learn to construct a medical note. While the longitudinal impact remains to be seen, it is clear patient-centered documentation skills should be an integral part of documentation education.
Effect of notes’ access and complexity on OpenNotes’ utility
Simplifying notes can improve understanding of notes for patients/families. However, perceived usability, cognitive workload, and satisfaction with even the simplified notes were still low. To make notes more useful for patients and their families, there is a need for dramatic improvements to the overall usability and content of the notes.
Internal medicine intern preparedness to document clinical encounters in the era of open notes: A needs assessment survey
[…] This study identifies a need to improve documentation education in the era of open notes. Additional research into the best ways to teach, write, and incorporate open notes into practice may empower trainees to use documentation to further improve patient care.
Clinical ethics consultation documentation in the era of open notes
The new regulatory requirements of the 21st Century Cures Act provide a valuable opportunity to involve patients more actively in the documentation and telling of their own story of ethical complexity. Healthcare systems should take advantage of this new era and use open notes as a way to improve CECs documentation and, ultimately, patient care.
Experiences with information blocking in the United States: A national survey of hospitals
We sought to describe hospital leaders’ perceptions of the prevalence of practices that may constitute information blocking, by actor and hospital characteristics, following the rule’s applicability date. These results […] support the need for continued observation to provide a sense of the prevalence of information blocking practices and for education and awareness of information blocking regulations.
The voice of the patient and the electronic health record
The patient’s voice […] and their preferences for care and its outcomes, is too small a part of the electronic health record (EHR). If you are a researcher or innovator, collaborate with patient groups and clinicians to create new ways to capture the patient voice, and to leverage it for good.
A patient-centered approach to writing ambulatory visit notes in the Cures Act era
Most note-writing guides to date have focused on the experience of clinicians. Here, we build on these tips by integrating patient perspectives related to note-reading.
Shared access to patient portals for older adults: Implications for privacy and digital health equity
This viewpoint article discusses challenges and opportunities of systematic engagement of care partners through shared access to the patient portal that have been amplified in the context of the COVID-19 outbreak and recent implementation of federal information blocking rules to promote information transparency alongside broader shifts toward care delivery innovation and population aging. We describe implementation considerations and the promise of granular, role-based privacy controls in addressing the nuanced and dynamic nature of individual information sharing preferences and fostering person- and family-centered care delivery.
Patient characteristics and utilization of an online patient portal in a rural academic general internal medicine practice
In a rural academic internal medicine clinic, female patients, aged 41–65, non-smokers, and those without certain chronic conditions were more likely to use an online patient portal. Recognizing and addressing barriers to patient portal use is essential for robust and sustained patient portal uptake and ensuring that the benefits of portal use are equally distributed among all patients.
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