key: cord-0047984-ai6ojdzc
authors: Kriegel, Gila; Bell, Sigall; Delbanco, Tom; Walker, Jan
title: Covid-19 as Innovation Accelerator: Cogenerating Telemedicine Visit Notes with Patients
date: 2020-05-12
journal: NEJM Catal Innov Care Deliv
DOI: 10.1056/cat.20.0154
sha: 5bcae554e5fe9084e07188ed3e85b8f6305fc37c
doc_id: 47984
cord_uid: ai6ojdzc

The coronavirus pandemic has catalyzed remote-access patient visits. Even for clinicians with telemedicine experience, the current environment presents numerous challenges. Clinicians at Beth Israel Deaconess Medical Center are developing tools to facilitate prework for telemedicine visits in order to enhance patient engagement and improve clinician workflow.

pilot program, and during the phone call the doctor found her patient's contributions particularly helpful. She suggested that soliciting additional pre-visit information from patients scheduled for telemedicine visits might address some of the clinicians' new challenges (see Appendix).

Funded by federal and philanthropic grants, and neither a software nor other product vendor, the rapidly expanding OpenNotes movement is based at BIDMC, and today, more than 45 million Americans have gained electronic access through patient portals to the notes their physicians and other practitioners write.1 , 2 About 60% of HCA patients are registered on BIDMC's patient portal and are able thereby to review their clinicians' visit notes, described at the hospital as OpenNotes.

One of the biggest challenges to clinicians was the lack of prework that previously would have been completed on site by medical assistants who measured vital signs, recorded the chief complaint, reconciled medications, and solicited requests for prescription renewals."

In addition, since February 2019, 20 volunteering HCA doctors have been participating in a pilot of OurNotes, inviting patients to contribute to their notes as a next step in the evolution of OpenNotes.3 Two days prior to a scheduled visit, patients have been receiving a portal message asking them to complete and return an electronic form on which they (a) provide a brief interval history, and (b) list their goals for the visit. Once submitted, the forms are saved as independent and permanent records, marked as "Patient Notes" in the electronic health record. Clinicians can review them prior to or during visits, and then either refer to them or incorporate them into the note itself by copying and pasting.

Parallel trials are taking place in primary care practices at Dartmouth-Hitchcock Medical Center, the University of Colorado, and University of Washington Medicine, with each institution documenting patients' contributions somewhat differently by adapting their own technologic and practice workflows. While the formal evaluation is incomplete, OurNotes has passed a pragmatic test at all four sites: At the end of the 12-month pilots, the doctors agreed to continue and further refine the intervention. Some related positive anecdotes, and others felt neutral, but none withdrew or have so far expressed distaste for the idea.

With the Covid-19 pandemic and the rapid implementation of telemedicine visits, we decided to expand OurNotes at HCA, tailoring it specifically for telemedicine. We collected informal feedback from the participating doctors, asking what additional information they might like to see prior to telemedicine visits. They were most interested in having patients add information about their medications and, for those with equipment at home, to take their vital signs and other measurements. We then drafted new questions for feedback and updated the pre-visit form and patient invitation for use in both telemedicine and in-person visits (see Appendix). 

As we gain experience with the new OurNotes form, we will continue to gather feedback from participating clinicians and patients about the effectiveness of the intervention and their ideas for improvement. We anticipate this will lead to iterative adjustments in the coming weeks and months, and eventually to a unified OurNotes pre-visit system that can be adopted broadly by BIDMC ambulatory care providers.

We suspect that patients and care partners may recall even less of telemedicine encounters than they do after face-to-face office visits, and that as a result they may turn more often to reading their OpenNotes online."

We will also address other feedback and suggestions. For example, we will experiment to determine what works best for the patient-generated interval history. Should it be structured or semi-structured, as opposed to free text? Or, as a patient and family advisory council at Stanford Children's Hospital recommended, should we offer patients both options? We hope also to find ways to incorporate seamlessly into the medical record vital signs and other measurements taken at home. And we will work to make adaptations for low-literacy patients and those with limited English proficiency.

Helping both patients and clinicians to maintain telemedicine relationships that lack an in-person, hands-on approach is a challenge. However, we may find a silver lining in the unfolding pandemic if the changes it stimulates in care delivery prove to be durable advances. We anticipate that the benefits of transparent communication can only be heightened by the demands of the pandemic. We suspect, for example, that patients and care partners may recall even less of telemedicine encounters than they do after face-to-face office visits,4 and that as a result they may turn more often to reading their OpenNotes online. Once patient-and clinician-friendly mechanisms are in place, we imagine also that inviting patients to contribute directly to their records will both support patient engagement and help clinician workflow.

We hope OurNotes will prove salutary as it and variations on the theme evolve. Telemedicine is no doubt here to stay.5 -7 We urge our colleagues nationwide to collaborate with one another and with diverse patients in developing next steps. 

OpenNotes after 7 years: patient experiences with ongoing access to their clinicians' outpatient visit notes

The views and experiences of clinicians sharing medical record notes with patients

Patients contributing to their Doctors' notes: insights from expert interviews

What did the doctor say? Health literacy and recall of medical instructions

Rapidly Converting to "Virtual Practices": Outpatient Care in the Era of Covid-19

Covid-19 and Health Care's Digital Revolution

Creating the New Normal: The Clinician Response to Covid-19

This work was supported by grants from the Commonwealth Fund of New York and the Drane Family Fund. We thank the patient for permission to cite her OurNotes submission.Disclosures: Gila Kriegel, Tom Delbanco, and Jan Walker were supported by grants from the Commonwealth Fund of New York and the Drane Family Fund. Sigall Bell reports funding from the Agency for Healthcare Research and Quality for separate but related work.