Background
Sharing outpatient notes with patients may bring clinically important benefits, but notes may sometimes cause patients to feel judged or offended, and thereby reduce trust.
Objective
As ...part of a larger survey examining the effects of open notes, we sought to understand how many patients feel judged or offended due to something they read in outpatient notes, and why.
Design
We analyzed responses from a large Internet survey of adult patients who used secure patient portals and had at least 1 visit note available in a 12-month period at 2 large academic medical systems in Boston and Seattle, and in a rural integrated health system in Pennsylvania.
Participants
Adult ambulatory patients with portal accounts in health systems that offered open notes for up to 7 years.
Approach
(1) Quantitative analysis of 2 dichotomous questions, and (2) qualitative thematic analysis of free-text responses on what patients found judgmental or offensive.
Key Results
Among 22,959 patient respondents who had read at least one note and answered the 2 questions, 2,411 (10.5%) reported feeling judged and/or offended by something they read in their note(s). Patients who reported poor health, unemployment, or inability to work were more likely to feel judged or offended. Among the 2,411 patients who felt judged and/or offended, 2,137 (84.5%) wrote about what prompted their feelings. Three thematic domains emerged: (1) errors and surprises, (2) labeling, and (3) disrespect.
Conclusions
One in 10 respondents reported feeling judged/offended by something they read in an outpatient note due to the perception that it contained errors, surprises, labeling, or evidence of disrespect. The content and tone may be particularly important to patients in poor health. Enhanced clinician awareness of the patient perspective may promote an improved medical lexicon, reduce the transmission of bias to other clinicians, and reinforce healing relationships.
Patient-clinician secure messaging is an important function in patient portals and enables patients and clinicians to communicate on a wide spectrum of issues in a timely manner. With its growing ...adoption and patient engagement, it is time to comprehensively study the secure messages and user behaviors in order to improve patient-centered care.
The aim of this paper was to analyze the secure messages sent by patients and clinicians in a large multispecialty health system at Mayo Clinic, Rochester.
We performed message-based, sender-based, and thread-based analyses of more than 5 million secure messages between 2010 and 2017. We summarized the message volumes, patient and clinician population sizes, message counts per patient or clinician, as well as the trends of message volumes and user counts over the years. In addition, we calculated the time distribution of clinician-sent messages to understand their workloads at different times of a day. We also analyzed the time delay in clinician responses to patient messages to assess their communication efficiency and the back-and-forth rounds to estimate the communication complexity.
During 2010-2017, the patient portal at Mayo Clinic, Rochester experienced a significant growth in terms of the count of patient users and the total number of secure messages sent by patients and clinicians. Three clinician categories, namely "physician-primary care," "registered nurse-specialty," and "physician-specialty," bore the majority of message volume increase. The patient portal also demonstrated growing trends in message counts per patient and clinician. The "nurse practitioner or physician assistant-primary care" and "physician-primary care" categories had the heaviest per-clinician workload each year. Most messages by the clinicians were sent from 7 AM to 5 PM during a day. Yet, between 5 PM and 7 PM, the physicians sent 7.0% (95,785/1,377,006) of their daily messages, and the nurse practitioner or physician assistant sent 5.4% (22,121/408,526) of their daily messages. The clinicians replied to 72.2% (1,272,069/1,761,739) patient messages within 1 day and 90.6% (1,595,702/1,761,739) within 3 days. In 95.1% (1,499,316/1,576,205) of the message threads, the patients communicated with their clinicians back and forth for no more than 4 rounds.
Our study found steady increases in patient adoption of the secure messaging system and the average workload per clinician over 8 years. However, most clinicians responded timely to meet the patients' needs. Our study also revealed differential patient-clinician communication patterns across different practice roles and care settings. These findings suggest opportunities for care teams to optimize messaging tasks and to balance the workload for optimal efficiency.
The COVID-19 pandemic accelerated telemedicine and mobile app use, potentially changing our historic model of maternity care. MyChart is a widely adopted mobile app used in health care settings ...specifically for its role in facilitating communication between health care providers and patients with its messaging function in a secure patient portal. However, previous studies analyzing portal use in obstetric populations have demonstrated significant sociodemographic disparities in portal enrollment and messaging, specifically showing that patients who have a low income and are non-Hispanic Black, Hispanic, and uninsured are less likely to use patient portals.
The study aimed to estimate changes in patient portal use and intensity in prenatal care before and during the pandemic period and to identify sociodemographic and clinical disparities that continued during the pandemic.
This retrospective cohort study used electronic medical record (EMR) and administrative data from our health system's Enterprise Data Warehouse. Records were obtained for the first pregnancy episode of all patients who received antenatal care at 8 academically affiliated practices and delivered at a large urban academic medical center from January 1, 2018, to July 22, 2021, in Chicago, Illinois. All patients were aged 18 years or older and attended ≥3 clinical encounters during pregnancy at the practices that used the EMR portal. Patients were categorized by the number of secure messages sent during pregnancy as nonusers or as infrequent (≤5 messages), moderate (6-14 messages), or frequent (≥15 messages) users. Monthly portal use and intensity rates were computed over 43 months from 2018 to 2021 before, during, and after the COVID-19 pandemic shutdown. A logistic regression model was estimated to identify patient sociodemographic and clinical subgroups with the highest portal nonuse.
Among 12,380 patients, 2681 (21.7%) never used the portal, and 2680 (21.6%), 3754 (30.3%), and 3265 (26.4%) were infrequent, moderate, and frequent users, respectively. Portal use and intensity increased significantly over the study period, particularly after the pandemic. The number of nonusing patients decreased between 2018 and 2021, from 996 of 3522 (28.3%) in 2018 to only 227 of 1743 (13%) in the first 7 months of 2021. Conversely, the number of patients with 15 or more messages doubled, from 642 of 3522 (18.2%) in 2018 to 654 of 1743 (37.5%) in 2021. The youngest patients, non-Hispanic Black and Hispanic patients, and, particularly, non-English-speaking patients had significantly higher odds of continued nonuse. Patients with preexisting comorbidities, hypertensive disorders of pregnancy, diabetes, and a history of mental health conditions were all significantly associated with higher portal use and intensity.
Reducing disparities in messaging use will require outreach and assistance to low-use patient groups, including education addressing health literacy and encouraging appropriate and effective use of messaging.
PurposeThe aim of the study was to incorporate the perspectives of both patients and providers into the development of training to improve the exchange of secure messages through a patient portal as ...well as to identify management strategies that support patient engagement.MethodologyThree patient focus groups (17 patients) and interviews with 21 ambulatory physicians across 17 outpatient clinics at a large Midwestern academic medical center using Epic MyChart were performed. Rigorous thematic analysis was guided by the Systems Engineering Initiative for Patient Safety 2.0 framework adapted to patient portal implementation.ResultsPatients and physicians identified strategies at the patient, portal, physician, and health system levels that could help each group navigate the portal to communicate via secure messages more efficiently. Patient-focused training strategies included multimodal materials addressing how to navigate portal features and direction on when, what, and how to message. Changes to the format of the messaging feature and pop-ups with communication tips were also frequently mentioned. Physician and clinic-level strategies focused on how the clinic and health system management could enhance physician training on the patient-facing portal features and on how to manage patient care within the portal. Physicians also requested that the health system administration standardize physician and care team work processes related to secure messages within the portal and communicate clear management expectations of physician portal management.ConclusionAs communication via secure messaging has become more common, our study identified patient, physician, portal and health system-level management and training strategies to enhance patient portal use.Practice ImplicationsHealth system administrators and outpatient clinic management could implement these strategies to clarify the rules of engagement in the collaborative work of incorporating a patient portal into the primary care workflow and facilitating provider and patient use.
Patient portal (PP) use has rapidly increased in recent years. However, the PP use status among houseless patients is largely unknown. We aim to determine 1) the PP use status among Emergency ...Department (ED) patients experiencing houselessness, and 2) whether PP use is linked to the increase in patient clinic visits.
This is a single-center retrospective observational study. From March 1, 2019, to February 28, 2021, houseless patients who presented at ED were included. Their PP use status, including passive PP use (log-on only PP) and effective PP use (use PP of functions) was compared between houseless and non-houseless patients. The number of clinic visits was also compared between these two groups. Lastly, a multivariate logistic regression was analyzed to determine the association between houseless status and PP use.
We included a total of 236,684 patients, 13% of whom (30,956) were houseless at time of their encounter. Fewer houseless patients had effective PP use in comparison to non-houseless patients (7.3% versus 11.6%, p < 0.001). In addition, a higher number of clinic visits were found among houseless patients who had effective PP use than those without (18 versus 3, p < 0.001). The adjusted odds ratio of houseless status associated with PP use was 0.48 (95% CI 0.46–0.49, p < 0.001).
Houselessness is a potential risk factor preventing patient portal use. In addition, using patient portals could potentially increase clinic visits among the houseless patient population.
Through its Public Release of Clinical Information initiative, Health Canada has provided public access to a vast repository of data that have been submitted to support market authorization of drugs ...and medical devices. Health Canada has released data from more than 160 submissions for drugs, biologics, vaccines and medical devices. The regulator is currently in its third year of a 4-year phase-in schedule to release clinical data proactively from submissions for all new active substances, new clinical indications, generic drugs and higher-risk devices that are approved, withdrawn or rejected. Substantial clinical data submitted by the industry sponsor of the application, including summary-level data and metadata are made publicly available by Health Canada as a matter of policy.
The Caryophyllales TEN is one of the Taxonomic Expert Networks for the World Flora Online (WFO, worldfloraonline.org). It was initiated in 2011 with the aim to create a global taxonomic synthesys of ...the angiosperm order Caryophyllales (about 6% of the angiosperm species). The network currently includes about 170 scientists from 36 countries. The first priority is creating a dynamic taxonomic backbone for the order using the EDIT Platform for Cybertaxonomy (cybertaxonomy.org).
One key product is an online portal (caryophyllales.org) that serves as a single entry point for expert-reviewed information. The EDIT Data Portal is one of the software components of the EDIT Platform (see the list of reference projects for further examples). Data entry, imports and editing is managed by the Taxonomic Editor component. Web services and data exchange via standardized formats will be used to connect to international biodiversity informatics initiatives such as the Global Biodiversity Information Facility and the International Plant Name Index. The data are available in a standardized format for open data exchange.
Completed checklist projects with accompanying data papers so far consist of a genus-level checklist of the whole order (Hernández-Ledesma et al. 2015) and species-level treatments for Nepenthaceae (Berendsohn et al. 2018), Cactaceae (Korotkova et al. 2021) and
Dianthus,
Caryophyllaceae (Fassou et al. 2022). The entire Caryophyllaceae, Plumbaginaceae and the Amaranthaceae are under revision, Aizoaceae and most of the smaller families have been revised based on literature. These projects all aimed to network existing specialists for the respective families and to produce checklists that reflect the current state of research on the given group, where possible based on phylogenetic studies.
The Caryophyllales TEN is coordinated by a scientist at the Botanic Garden Berlin but otherwise has no explicit governance or committees. The experiences from the aforementioned projects allow for some general insights as to organizing and maintaining a taxonomic expert network. Whereas a scientific network is usually a relatively loose connection between collaborators with varying levels of commitment over time, a strong expert network that works towards a specific product needs a firmer structure. According to our experience, five aspects are important.
1. Clarity. A clearly defined framework which can include the written summary of the rationale and the main underlying principles, detailed editorial guidelines and guidelines for contributors, best-practice recommendations, a clear outline of different roles which experts can have in the project, and requirements for authorship on resulting publications.
2. Flexibility. The framework should be defined in a way that it still allows flexible approaches to the individual projects and the roles that can account for varying levels of commitment and needs of individual researchers.
3. Community aspect. Bringing experts together regularly through in-person conferences or virtual meetings is essential to keep the network going. Participation should be open for everyone who is interested, regardless of career level and there should be different lowthreshold “entry points”. These can be participation in a conference, being invited to contribute to a checklist or seeking out other experts for collaboration. Already active experts can engage and further connect people to the network, thus creating a large and strong community.
4. Credits. Our policy is that each source is referenced and each individual contribution is acknowledged in the data paper and online portal. This aims at increasing the visibility of research results and developing best-practice approaches within the community.
5. Incentives and commitment. People will participate in such networks because they have a strong personal interest to invest their time and energy in a project that is valuable to them and aligns with their own goals. Expert networks need committed people and therefore, there must be strong incentives, for example being part of a widely known and highly visible initiative or co-authoring a key data paper.
Prior research on the digital divide has documented substantial racial inequality in using web-based health resources. The recent COVID-19 pandemic led to accelerated mass digitization, raising ...alarms that underprivileged racial minority groups are left further behind. However, it is unclear to what extent the use of health information and communications technology by underprivileged racial minority groups is affected.
We have considered the COVID-19 disruption as a rare exogenous shock and estimated the impact of the accelerated digitization on the quantity and variety of patient portal use. In this study, we aimed to answer the following 2 key research questions. Did patients alter their use of health information and communications technology owing to COVID-19-induced digital acceleration? Does the effect differ across racial lines?
We used a longitudinal patient portal use data set gathered from a large urban academic medical center to explore the effect of accelerated digitization on the racial digital gap in health care. We limited the sample period of our study to 2 same periods (March 11 to August 30) in 2019 and 2020. Our final sample consisted of 25,612 patients belonging to 1 of the 3 racial groups: Black or African American (n=5157, 20.13%), Hispanic (n=253, 0.99%), and White (n=20,202, 78.88%) patients. We estimated the panel data regression using 3 different models: pooled ordinary least squares (OLS), random effect (RE), and fixed effect (FE).
Our study yielded 4 findings. First, we confirmed that the racial digital divide remains a significant issue for telehealth; underprivileged racial minority group patients had lower patient portal use than White patients before the pandemic (Minority: OLS, β=-.158; P<.001; RE, β=-.168; P<.001). Second, we found that the digital gap regarding patient portal use frequency between underprivileged racial minority groups and White patients is shrinking rather than widening after the COVID-19 pandemic started (COVID_Period×Minority: OLS, β=.028; P=.002; RE, β=.037; P<.001; FE, β=.043; P<.001). Third, the shrinking gap is foremost driven by access through mobile (vs desktop) devices (COVID_Period×Minority: web, β=-.020; P=.02; mobile, β=.037; P<.001). Finally, underprivileged racial minority groups expanded their use of a variety of portal functionalities faster than White patients during the pandemic (COVID_Period×Minority for functionality: OLS, β=-.004; P<.001; RE, β=-.004; P<.001; FE, β=-.003; P=.001).
Using the COVID-19 pandemic as a natural experiment, we offer empirical evidence that accelerated digitization has shrunk the racial digital divide in telehealth, and the trend is mostly driven by mobile devices. These findings provide new insights into the digital behaviors among underprivileged racial minority groups during accelerated digitization. They also offer policy makers an opportunity to identify new strategies to help close the racial digital gap in the postpandemic world.
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