How might AI, digital health technologies, and open notes transform diagnosis while addressing health disparities? Read highlights from the National Academies Forum on Advancing Diagnostic Excellence.
Implementation
Guidelines for Patient-Centered Documentation in the Era of Open Notes: A Qualitative Study
This study by Vanka, et al, presents 10 guidelines for patient-centered medical documentation, emphasizing respect, clarity, and inclusivity in clinical notes. These principles aim to empower patients, improve trust, and enhance medical education on open notes practices.
Study: Leveraging a patient portal to help patients formulate their healthcare goals
This study tested self-directed tools for older adults with chronic conditions to identify healthcare priorities. Website engagement was low, but 26% completed an Epic previsit questionnaire. Most found it helpful, and physicians noted it facilitated end-of-life care discussions.
When bad news comes through the portal: Strengthening trust and guiding patients when they receive bad results before their clinicians
In this chapter, perspectives from a patient with cancer, an oncologist, and a cancer psychiatrist (in that order) are shared to illuminate the adjustments made in clinician-patient communication amid the era of nearly instantaneous results within the electronic health record.
Psychiatrists’ perceptions of conditions and consequences associated with the implementation of open notes: Qualitative investigation
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.
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.
Except where otherwise noted, the content by OpenNotes is licensed under a Creative Commons Attribution 4.0 International License.
