Annals of Family Medicine Research

Physicians, Patients Collaborate to Generate Visit Notes

March 28, 2017 04:22 pm Sheri Porter

Results of new research published in the March/April issue of Annals of Family Medicine(www.annfammed.org) highlight the benefits accrued to both patients and primary care clinicians when patients were encouraged to type part of their own visit note into the electronic health record (EHR) to detail their expectations for the medical appointment.  

A total of 101 patients at Harborview Medical Center, a safety-net county hospital in Seattle, did just that during a study conducted from June 9 to July 22, 2015. The results of that research, captured in an article titled "Patients Typing Their Own Visit Agendas Into an Electronic Medical Record: Pilot in a Safety-Net Clinic," reflected all-around satisfaction.

"Agenda perceptions were strongly positive among both patients and clinicians," wrote the authors. "Patients and clinicians felt this improved communication and both expressed interest in patient-written agendas in the future," they added.

Authors highlighted the widely known OpenNotes(www.opennotes.org) initiative that launched in 2010 and that invites patients to review chart notes written by their physicians and other health care professionals. Research on the use of OpenNotes has revealed overwhelmingly positive support, but this latest work "is the first OpenNotes study of co-generation of clinic notes," said authors.

And the timing couldn't be better, given health care stakeholders' keen interest in motivating patients to become engaged in their own health care, they added.  

Story Highlights
  • Researchers at a safety-net county hospital in Seattle had patients type their specific visit agenda into the electronic health record as they waited to see the clinician.
  • Clinicians read the patient's agenda before or upon entering the exam room.
  • Patients and clinicians thought this improved communication, and both expressed interest in continuing patient-written agendas in the future.
     

Corresponding author Joann Elmore, M.D., M.P.H., professor of medicine and adjunct professor of epidemiology at the University of Washington School of Medicine in Seattle, told AAFP News that the purpose of the study was to assess the feasibility, acceptability and utility of having patients who attend a large primary care safety-net clinic type their agendas into the electronic visit note before seeing their clinicians.

At the study's conclusion, "there was resounding enthusiasm from both patients and their clinicians," said Elmore.

She shared some personal history that helps explain her interest in the topic, including her longtime passion for providing high-quality patient care and her frustration with EHRs. "I care about the art of clinical practice; I do not want to be the doctor who's always looking at a computer screen," she said.

But Elmore -- who also sees patients in an adult medicine clinic -- was spending many hours on weekends inputting her clinic notes into the EHR.

"During my early attempts at figuring out how to be more efficient in clinic, I would turn the computer screen toward the patient and say, 'What do you think I should write here?'"

On one occasion, a patient noticed that Elmore was a "slow and terrible" typist.

"She took the keyboard away from me and said, 'Doc, let me help you.' And she thought it was so much fun. She wanted me to dictate to her," said Elmore.

"And I said, 'No, you're the one who should be helping me co-write this, and so she and I wrote that visit note together as a team."

Study Methodology

Patients who agreed to participate were met in the waiting room by the research assistant when they arrived at the clinic for their appointments. The assistant stayed with patients while they typed their visit agendas into the EHR via a laptop computer.

The patient's entry was placed in the clinician's "progress notes" field and clearly labeled as a patient note that remained part of the permanent visit record. Clinicians reviewed the patient portion of the note before or upon entering the exam room.

Patients ranged in age from 18 to older than 70. Selection depended on their English proficiency and comfort level with keyboarding.

Participants were asked to arrive for their appointment 30 minutes early. However, most patients finished their task quickly; 83 percent typed for less than 10 minutes, and 80 percent wrote a note shorter than 60 words.

Patients' comments often were brief and to the point. One wrote, "My ankle is not getting better." Another keyed in, "The boot is giving me knee problems."

In a follow-up survey, patient comments about the experience were insightful. For example, "Doctor and I on the same page," said one. Another patient noted, "Gave doctor my information so I wouldn't be nervous and forget." Then there was this: "New doctor so this was excellent way of getting my feelings across."

Clinicians liked the concept, too. One said the patient-generated note gave her time to think about issues ahead of time. Another said the patient was more engaged and felt "heard."

A high percentage of both clinicians and patients said patient-written agendas served to

  • better prepare clinicians,
  • improve clinician understanding of patient concerns,
  • achieve a more efficient visit,
  • prioritize the visit and
  • improve patient-clinician communication.

Patients and clinicians expressed interest in continuing patient-written agendas in the future, wrote the authors.

Next Steps

Elmore mentioned some key findings worth remembering.

"This kind of collaboration between clinicians and their patients can flourish anywhere, even within settings that care for vulnerable patient populations," said Elmore. "We did this study at a county hospital where we have homeless patients who access their records on cellphones or on library computers; they are interested and able to participate.

"Patients want to help us," she added.

Elmore conceded that patient-generated notes often were more typo-laden than even her own. "But they sometimes wrote things I don't think they would have said to me verbally."

As for the future, Elmore would like to see EHRs help push health care to the next wave of patient-note co-generation.

Exactly what would that look like?

"We would have patients sending us their agendas in advance of their appointments using the patient portal, or they would type their agendas on computers in the waiting room. These patient-typed agendas would then automatically be inserted into the doctor's visit notes. That would save us time, and it would help patients to be more involved," said Elmore.

Overall, the study's authors came to this conclusion: "Patient-written visit agendas could increase the collaborative nature of the clinical encounter between patient and clinician, but require further study, including measurement of patient engagement and health outcomes."

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