The Importance of Visit Notes on Patient Portals for Engaging Less Educated and Nonwhite Patients: Survey Study

Abstract

BackgroundOpenNotes, a national initiative to share clinicians’ visit notes with patients, can improve patient engagement, but effects on vulnerable populations are not known very well.ObjectiveOur aim is to examine the importance of visit notes to nonwhite and less educated patients.MethodsPatients at an urban academic medical center with an active patient portal account and ≥1 available ambulatory visit note over the prior year were surveyed during June 2016 until September 2016. The survey was designed with patients and families and assessed importance of reading notes (scale 0-10) for (1) understanding health conditions, (2) feeling informed about care, (3) understanding the provider’s thought process, (4) remembering the plan of care, and (5) making decisions about care. We compared the proportion of patients reporting 9-10 (extremely important) for each item stratified by education level, race/ethnicity, and self-reported health. Principal component analysis and correlation measures supported a summary score for the 5 items (Cronbach alpha=.93). We examined factors associated with rating notes as extremely important to engage in care using logistic regression.ResultsOf 24,722 patients, 6913 (27.96%) completed the survey. The majority (6736/6913, 97.44%) read at least one note. Among note readers, 74.0% (727/982) of patients with ≤high school education, 70.7% (130/184) of black patients, and 69.9% (153/219) of Hispanic/Latino patients reported that notes are extremely important to feel informed about their care. The majority of less educated and nonwhite patients reported notes as extremely important to remember the care plan (62.4%, 613/982 ≤high school education; 62.0%, 114/184 black patients; and 61.6%, 135/219 Hispanic/Latino patients) and to make care decisions (62.3%, 612/982; 59.8%, 110/184; and 58.5%, 128/219, respectively, and P<.003 for all comparisons to more educated and white patients, respectively). Among patients with the poorest self-reported health, 65.9% (499/757) found notes extremely important to be informed and to understand the provider. On multivariable modeling, less educated patients were nearly three times as likely to report notes were extremely important to engage in care compared with the most educated patients (odds ratio [OR] 2.9, 95% CI 2.4-3.3). Nonwhite patients were twice as likely to report the same compared with white patients (OR 2.0, 95% CI 1.5-2.7 [black] and OR 2.2, 95% CI 1.6-2.9 [Hispanic/Latino and Asian], P<.001 for each comparison). Healthier patients, women, older patients, and those who read more notes were more likely to find notes extremely important to engage in care.ConclusionsLess educated and nonwhite patients using the portal each assigned higher importance to reading notes for several health behaviors than highly educated and white patients, and may find transparent notes especially valuable for understanding their health and engaging in their care. Facilitating access to notes may improve engagement in health care for some vulnerable populations who ha...

Empowering patients and reducing inequities: is there potential in sharing clinical notes?

“…Open notes might be viewed as extending the visit, potentially thereby elongating and strengthening patient–physician interactions before and after the pressures of the clinical encounter 1 3 4. It is reasonable to postulate that this perceived elongation of the visit through online access to notes may reduce anxiety, negative emotions and poor recall associated with stereotype threat 14.…”

“…However, for many reasons, persons from these demographic groups are less likely to use health portals than other patient populations 5. Drawing on promising preliminary evidence,2–4 6 we suggest that open notes may, over time, prove important in the care of patients who are at risk of experiencing healthcare disparities.…”

“…Patients who read their clinical notes via online patient portals (‘open notes’) report that doing so engages them actively in their care, improves their sense of control over their health and enhances safety 1–3. In several surveys, patients who are older, less educated, non-white or whose first language is not English report even greater benefits than do their counterparts 2–4. However, for many reasons, persons from these demographic groups are less likely to use health portals than other patient populations 5.…”

Analysis of Employee Patient Portal Use and Electronic Health Record Access at an Academic Medical Center

“…Studies have demonstrated that reading clinical notes can be essential to understanding the health condition and care plans, and encouraging patients' engagement in their decision making regardless of having a medical degree. 42,44 Employees who accessed only the EHR and did not have a MHAV account still viewed their notes more than any other document in the EHR. Although they did not message their providers through our studied information systems, they read the messages sent between care team members.…”

“…[39][40][41] Studies of OpenNotes have evaluated the patients' understanding of their health conditions, recalling care plans, and participation in shared decision making. 42,43 In one study to evaluate granting access to minority patients to read their clinical notes, authors found that black, Hispanic, and Asian patients indicated that reading notes was highly important. 43 Another study found that patients who read at least four clinical notes in a year were more likely to be involved in the decision-making process of their care plan.…”