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Study: Letting Patients enter EHR Notes Ahead of Office Visit Improves Patient-clinician Communication

Patients enter EHR Notes Ahead of Office VisitEven in the electronic health record (EHR) era, outsourcing medical transcription continues to be a viable solution when it comes to maintaining accurate and timely medical records. Expert medical transcriptionists provide dedicated EHR-integrated documentation solutions that allow providers to focus on care rather than EHR data entry.

A new study has found that patients can play a meaningful role in helping physicians generate EHR notes. The OpenNotes study published in the research published in the March/April issue of Annals of Family Medicine reports that both patients and primary care physicians would benefit when patients were allowed to enter type a portion of their own visit note in their EHR ahead of the office visit. The researchers found that this strategy could better prepare clinicians, improve the efficiency of the office visit, and enhance patient-clinician communication.

A total of 101 patients of Harborview Medical Center Adult Medicine Clinic in Seattle, WA, were chosen to participate in the study. The patients were met in the waiting room by a research assistant and provided with a laptop computer with the clinic’s [EHR/EMR] interface. They typed their agenda into the EHR and the entry was put in the clinician’s “progress notes” field and marked as a patient note to become a part of the permanent visit record. Their 28 clinicians reviewed these patient self-entered notes either before or when they entered the exam room and completed post-visit surveys.

The participants contributed to their notes and detailed their expectations for the medical appointment. The post-visit survey revealed that both patients and physicians were positive about the experience and strongly agreed to the following statements:

  • Made the clinicians more prepared (78% of providers, 82% of patients)
  • Improved clinician understanding of patient concerns (74% of providers, 75% of patients)
  • Made the visit more efficient (63% of providers, 79% of patients)
  • Helped prioritize the visit (82% of providers, 84% of patients)
  • Improved patient clinician communication (74% of providers, 79% of patients)
  • Want to use patient agendas in the future (82% of providers, 73% of patients)

Patients’ comments revealed their positive experience. One patient said: “Doctor and I on the same page,” said one. Another patient noted, “New doctor so this was excellent way of getting my feelings across.”

Clinicians’ comments were also insightful. For example, “Got time to think about issues ahead of time” and, “Engaged patient to participate more in the visit; he felt heard.”

Although the authors concede that their study had its limitations, they point out that patient generated notes can reveal how they are really feeling. This can prove very valuable in improving the patient-physician relationship. The strategy could also save money if physicians could better address patients’ concerns during the clinic visit, which would reduce the chances of their returning to the clinic or visiting the emergency room.

Medical transcription companies provide EHR-integrated documentation solutions for clinicians’ progress notes, H&P reports, diagnosis and treatment plans, emergency reports, surgical reports, examination reports, lab reports, and discharge summaries. Such support goes a long way in improving physician-patient interactions during the office visit.

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