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BackgroundInviting patients to read their primary care visit notes may improve communication and help them engage more actively in their health care. Little is known about how patients will use the opportunity to share their visit notes with family members or caregivers, or what the benefits might be. ObjectiveOur goal was to evaluate the characteristics of patients who reported sharing their visit notes during the course of the study, including their views on associated benefits and risks. MethodsThe OpenNotes study invited patients to access their primary care providers’ visit notes in Massachusetts, Pennsylvania, and Washington. Pre- and post-intervention surveys assessed patient demographics, standardized measures of patient-doctor communication, sharing of visit notes with others during the study, and specific health behaviors reflecting the potential benefits and risks of offering patients easy access to their visit notes. ResultsMore than half (55.43%, 2503/4516) of the participants who reported viewing at least one visit note would like the option of letting family members or friends have their own Web access to their visit notes, and 21.70% (980/4516) reported sharing their visit notes with someone during the study year. Men, and those retired or unable to work, were significantly more likely to share visit notes, and those sharing were neither more nor less concerned about their privacy than were non-sharers. Compared to participants who did not share clinic notes, those who shared were more likely to report taking better care of themselves and taking their medications as prescribed, after adjustment for age, gender, employment status, and study site. ConclusionsOne in five OpenNotes patients shared a visit note with someone, and those sharing Web access to their visit notes reported better adherence to self-care and medications. As health information technology systems increase patients’ ability to access their medical records, facilitating access to caregivers may improve perceived health behaviors and outcomes.

BackgroundOffering patients online access to medical records, including doctors’ visit notes, holds considerable potential to improve care. However, patients may worry about loss of privacy when accessing personal health information through Internet-based patient portals. The OpenNotes study provided patients at three US health care institutions with online access to their primary care doctors’ notes and then collected survey data about their experiences, including their concerns about privacy before and after participation in the intervention. ObjectiveTo identify patients’ attitudes toward privacy when given electronic access to their medical records, including visit notes. MethodsThe design used a nested cohort study of patients surveyed at baseline and after a 1-year period during which they were invited to read their visit notes through secure patient portals. Participants consisted of 3874 primary care patients from Beth Israel Deaconess Medical Center (Boston, MA), Geisinger Health System (Danville, PA), and Harborview Medical Center (Seattle, WA) who completed surveys before and after the OpenNotes intervention. The measures were patient-reported levels of concern regarding privacy associated with online access to visit notes. Results32.91% of patients (1275/3874 respondents) reported concerns about privacy at baseline versus 36.63% (1419/3874 respondents) post-intervention. Baseline concerns were associated with non-white race/ethnicity and lower confidence in communicating with doctors, but were not associated with choosing to read notes or desire for continued online access post-intervention (nearly all patients with notes available chose to read them and wanted continued access). While the level of concern among most participants did not change during the intervention, 15.54% (602/3874 respondents, excluding participants who responded “don’t know”) reported more concern post-intervention, and 12.73% (493/3874 respondents, excluding participants who responded “don’t know”) reported less concern. ConclusionsWhen considering online access to visit notes, approximately one-third of patients had concerns about privacy at baseline and post-intervention. These perceptions did not deter participants from accessing their notes, suggesting that the benefits of online access to medical records may outweigh patients’ perceived risks to privacy.

INTRODUCTION/OBJECTIVES: We examined an initial step towards co-generation of clinic notes by inviting patients to complete a pre-visit questionnaire that could be inserted into clinic notes by providers and describe the experience in a safety-net and non-safety-net clinic. METHODS: We sent an electronic pre-visit questionnaire on visit goals and interim history to patients at a safety-net clinic and a non-safety-net clinic before clinic visits. We compared questionnaire utilization between clinics during a one-year period and performed a chart review of a sample of patients to examine demographics, content and usage of patient responses to the questionnaire. RESULTS: While use was low in both clinics, it was lower in the safety-net clinic (3%) compared to the non-safety-net clinic (10%). We reviewed a sample of respondents and found they were more likely to be White compared to the overall clinic populations (p

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.

BACKGROUND: Clinicians are increasingly sharing outpatient visit notes with patients through electronic portals. These open notes may bring about new educational opportunities as well as concerns to physicians-in-training and residency programs. OBJECTIVE: We assessed anticipatory attitudes about open notes and explored factors influencing residents propensity toward note transparency. METHODS: Residents in primary care clinics at 4 teaching hospitals were surveyed prior to implementation of open notes. Main measures included resident attitudes toward open notes and the anticipated effect on patients, resident workload, and education. Data were stratified by site. RESULTS: A total of 176 of 418 (42%) residents responded. Most residents indicated open notes would improve patient engagement, trust, and education but worried about overwhelming patients, residents being less candid, and workload. More than half of residents thought open notes were a good idea, and 32% (56 of 176) indicated they would encourage patients to read these notes. More than half wanted note-writing education and more feedback, and 72% (126 of 175) indicated patient feedback on residents notes could improve communication skills. Attitudes about effects of open notes on safety, quality, trust, and medical education varied by site. CONCLUSIONS: Residents reported mixed feelings about the anticipated effects of sharing clinical notes with patients. They advocate for patient feedback on notes, yet worry about workload, supervision, and errors. Training site was correlated with many attitudes, suggesting local culture drives resident support for open notes. Strategies that address resident concerns and promote teaching and feedback related to notes may be helpful.

ObjectiveTo examine whether patients invited to review their clinicians' notes continue to access them and to assess the impact of reminders on whether patients continued to view notes.Materials and methodsWe followed OpenNotes trial participants for 2 years at Beth Israel Deaconess Medical Center (BIDMC) and Geisinger Health System (GHS). Electronic invitations alerting patients to signed notes stopped at GHS after year 1, creating a natural experiment to assess the impact of reminders. We used generalized linear models to measure whether notes were viewed within 30 days of availability.ResultsWe identified 14 360 patients (49 271 visits); mean age 52.2; 57.8% female. In year 1, patients viewed 57.5% of their notes, and their interest in viewing notes persisted over time. In year 2, BIDMC patients viewed notes with similar frequency. In contrast, GHS patients viewed notes far less frequently, a change starting when invitations ceased (RR 0.29 [0.26-0.32]) and persisting to the end of the study (RR 0.20 [0.17-0.23]). A subanalysis of BIDMC patients revealed that black and other/multiracial patients also continued to view notes, although they were overall less likely to view notes compared with whites (RR 0.75 [0.67-0.83] and 0.93 [0.89-0.98], respectively).DiscussionAs millions of patients nationwide increasingly gain access to clinicians' notes, explicit email invitations to review notes may be important for fostering patient engagement and patient-doctor communication.ConclusionNote viewing persists when accompanied by email alerts, but may decline substantially in their absence. Non-white patients at BIDMC viewed notes less frequently than whites, although their interest also persisted.

Objectives: To understand behaviors and attitudes of adults with diabetes who read their clinicians' visit notes. Methods: By linking a large 2017 patient survey involving three institutions with administrative and portal use data, we identified patients with diabetes mellitus from outpatient records and examined reading behaviors related to eligible notes—initial, follow-up, history and physical, and progress notes. We analyzed patients' perceived benefits of reading notes. Results: 2104 respondents had diagnoses of diabetes mellitus and had read ≥1 note in the 12-month period. Patients had an average of 8.7 eligible notes available and read 59% of them. The strongest predictor of reading more notes was having more notes available; the specialties of the authoring clinicians were not correlated with note reading rates. Patients reported understanding notes by primary care clinicians and specialists equally well; more than 90% of patients reported understanding everything or almost everything in a self-selected note. Across visit types, 73–80% of patients reported that note reading was extremely important for taking care of their health. Discussion: People with diabetes want to read their clinicians' notes, are accessing them at high rates, and report understanding the notes and benefiting from reading them. [ABSTRACT FROM AUTHOR]

Effective schools research gave birth to a new role for principals: instructional leader. Recent studies have suggested the relationship between strong school instructional leadership and higher student achievement. Skeptics question whether the principal's job is realistic and reasonable, with its emphasis on instructional leadership, multiple managerial responsibilities, and conflicting time demands. A more crucial question is, can the job allow the principal more time for instructional pursuits to provide greater impact on student learning? The answer to which this article explores. (Contains 1 table.)

This study was designed to analyze the hiring criteria of principals in Iowa to determine whether districts were seeking the characteristics of second-order change in their principals. Using content analysis, hiring criteria provided by districts were coded to identify those that described second-order change responsibilities per Mid-continent Research for Education and Learning's Balanced Leadership Framework. There was little congruence between the hiring criteria and the characteristics of second-order change. The results revealed that only 21% of the criteria were coded as second-order change, 46% of the districts did not use written criteria, and those hiring secondary principals were half as likely to include second-order change characteristics as those seeking elementary principals. The authors provide recommendations for districts and higher education as they seek school leaders who can initiate significant change.

The research reported in this paper attempted to identify predictors of senior center participation and to ascertain why there has been a decline in the number of individuals participating at senior centers in recent years. The research reports the results of a survey conducted among senior center participants in an 11-county area in the Nortex Area Agency on Aging region. A similar survey was conducted among the directors of 18 senior centers in the same region to determine their perspective on predictors of senior center participation. A qualitative review of senior center participants, directors, and non-participants was conducted to determine if there are trends for future research that were not captured in the quantitative analysis. Five predictors of senior center participation were found to be statistically significant: (1) Attendance at faith-based organizations (e.g., church); (2) Number of senior adults participating at any given time; (3) Number of center activities provided for senior adults; (4) The age of the participants; and (5) transportation available for participants. Although the variance explained was only 16%, the qualitative assessment validates the outcomes from the quantitative analysis. Therefore, eight recommendations are made for improving senior center participation that can be used in didactic instruction at the university level or in continuing education programs. In addition, we include additional questions for future research to identify other potential predictors of senior center participation.

Couples with chronically ill children are particularly at risk for experiencing marital distress. The study presented here is a 2-year follow-up of a randomized control trial that assessed the efficacy of Emotionally Focused Therapy (EFT) in decreasing marital distress in a sample of couples with a chronically ill child. Thirteen couples with chronically ill children who received treatment were assessed to determine if the significant improvement in relationship distress observed at posttreatment and 5-month follow-up would be maintained at 2-year follow-up. Results demonstrated that improvements in marital functioning were not only maintained but, in some cases, enhanced at the 2-year follow-up. This uncontrolled follow-up study provides initial evidence of the longer-term benefits of EFT.

Full-service schools are "seamless institutions" whose school leaders act as full partners with other community agencies to address student and family needs. Iowa's School-Based Youth Services Program is a "one-stop shopping" plan that has received national recognition. Marshaltown, Iowa's Caring Connection program is profiled. (Contains 14 references.) (MLH)