This project was supported in part by Department of Health and Human Services/Michigan Department of Community Health. RC103164 “2014-2015 Health Information Technology Resource Center.” 10/01/2014-09/30/2015.
Corser, W., Dontje, K., Neuberger, M., Chant, E., & Keskimaki, A. (Fall 2017). Reformatting “After Visit Patient Summaries”: A patient perspective. Online Journal of Nursing Informatics (OJNI),21(3), Available at http://www.himss.org/ojni
Since 2009, the United States government has incentivized healthcare providers such as advanced practice nurses to create personalized after-visit summaries (AVS) for patients as a measure of meaningful use of the electronic heath record (EHR). Under such incentives, the AVS has been envisioned as a continuity of care tool to provide key health information to patients and improve cross-provider healthcare coordination. The purpose of this paper is to report the qualitative analyses of a convenience analysis of 245 participants’ data related to AVS formatting and use. Two research assistants conducted 10-minute, private semi-structured interviews of participants concerning their views on the personalized AVS. Transcribed interview responses were analyzed and coded into major themes following an established qualitative content analysis analytic sequence. Results demonstrate the challenges in actualizing the potential for AVS tools to facilitate provider-patient communication. Participants did identify ambiguous, contradictory and absent data in their AVS documents and were concerned that they could not directly update healthcare data themselves. One of the challenges related to use of medical terminology, which was often difficult for the participants to interpret. Further studies are needed to develop strategies on how patients, office-based nurse practitioners, physicians and physician assistants can meet the potential for EHR-generated tools such as the AVS to facilitate patient engagement and continuity of care. An improved understanding of how organizational and other forces may impede patients from entering and deriving meaningful key health information from such tools is required.
Reformatting “After Visit Patient Summaries”: A Patient Perspective
Since 2009, the United States government, as part of the “meaningful use” of electronic health records (EHR) (Center for Medicare and Medicaid Services, 2013), has incentivized healthcare providers such as advanced practice nurses to deliver after-visit summaries (AVS) to their patients. The AVS was originally envisioned as an EHR-generated tool to provide key health information to patients that provides relevant information to improve both patient-provider decision-making and cross-provider healthcare coordination efforts (Hummel and Evans, 2012; Institute of Medicine, 2014; Beard, Schein, Morra, Wilson, & Keelan, 2012). The challenge is to determine if these tools are actually working to engage patients and improve their communication with healthcare providers.
Under qualification parameters for such incentives, personalized AVS documents can be handed directly to patients, later mailed to them, or provided electronically via secure email messages using patient health portals (Institute of Medicine, 2014; Dontje, Corser, & Holzman, 2014). In most modern EHR systems, customized AVS documents are generated for office visit patients to summarize patient-provider discussions and help them and family members address their needs between healthcare encounters (Corepoint Health, 2016; Hummel and Evans, 2012; Parker and Wolf, 2015).
Although more than 50% of U.S. patients now receive some form of office visit AVS, the specific content, formatting and graphical elements typically preferred by office visit patients remains largely unknown (Neter and Brainin, 2012; Pavlik, Brown, Nash & Gossey, 2014). Earlier projects have shown that some patients had hoped to have more direct interaction with the record, including the ability to update the information listed on their AVS (Chung and Basch, 2015; Emani, et al., 2014). However, one larger American study indicated that over 75% of nurse and physician providers possessed concerns about the impact of the AVS on their personal and staff workloads (Emani, et al., 2014). The sample primary care providers (i.e., total of about 30 different nurse practitioners, physicians and physician assistants) in the two clinics for this study were anecdotally found to possess somewhat varied perceptions of the AVS, perhaps due to their roles typically coordinating healthcare services more frequently than specialists.
One key construct frequently associated with the usability of healthcare information tools is“health literacy,”which is defined as “the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed
to make appropriate health decisions”(Koh, Brach, Harris, & Parchman, 2013, p.357). Several studies have suggested that providing patients with both verbal information and written instructions may have a greater impact on patients’ retention of provider recommendations than simple verbal instructions (Hummel and Evans, 2012; Institute of Medicine, 2014; Koh, et. al., 2013; Koh, Berwick, Clancy, Baur, Brach, Harris, & Zerhusen, 2012). The question that remains is how to design these written instructions in a way that is usable by patients. So much of the information that is provided to patients is steeped in medical terminology and jargon.
The related phenomenon of “eHealth literacy” has also been used to describe how healthcare consumers can use and understand the growing volume of electronic health information they receive from office visit AVS, websites, etc. (Koh, et. al., 2012; National Academy of Sciences, Engineering and Medicine, 2015). The importance of eHealth literacy for consumers to correctly interpret healthcare information has been initially shown in studies first correlating lower levels of eHealth with considerable health outcomes disparities (National Academy of Sciences, Engineering and Medicine, 2015).
The purpose of this paper is to report the analyses of 245 interview comments regarding AVS formatting and content preferences obtained during a 2014 mixed methods pilot project. The authors were specifically interested in examining what a sample of typical patients thought of their respective AVS documents shortly after receiving them. A convenience sample of 209 patients were interviewed shortly after having received their customized office visit AVS. Although the overall quantitative AVS usage patterns from this study have been summarized in another published report, (Neuberger, Dontje, Corser, Holzman, Chant & Keskimaki, 2014) the qualitative analyses of AVS suggestions obtained from sample patients is the focus of this second paper.
The authors enrolled a convenience sample of 209 office patients receiving care at either
of two Midwestern Family Medicine clinics. Both study clinics had a total of between 10 and 20 nurse practitioner, physician and physician assistant providers on staff and served patients who were between 60% to 90% Medicaid or Medicare-covered. The study design had received IRB approval from the authors’ university and an area health system before any data collection was begun. Consented patients (hereafter referred to as “participants”) were invited to complete a single voluntary post-office visit study interview without compensation.
Participants each completed the 10-minute, private semi-structured interview with one of two trained research assistants. The formulated standard interview script used with each patient had been developed by the authors and had not been specifically tested for its psychometric properties. This script was, however, loosely based on several of the authors’ earlier EHR study projects (Corser and Dontje, 2011; Dontje, et. al., 2014). Script items included: a) seven socio-demographic enrollment questions, followed by b) a series of 12 Yes-No or open-ended type questions primarily concerning participants’ initial AVS perspectives and improvement suggestions.
The four following open-ended questions were asked in the interview script:
- “What are your first impressions of your AVS?”
- “What do you plan to do with this AVS?”
- “Please explain.” (if participant wished to expand on Question 2)
- “Do you have any suggestions for the way health information or instructions are provided on your AVS?”
Although the two sample clinics had implemented different EHR systems, the study team determined that the clinics’ AVS formatting modules appeared to be quite similar. Following the interactive group analytic sequence of an established content analysis method (Krippendorf, 2004; Silverman, 2007), all qualitative interview comments were first transcribed verbatim by the research assistants into a word processing program. Next, comments were individually analyzed and coded into emerging themes by the authors during a series of four analytic team meetings held over a four-month period. The analysis and coding followed the same analytic sequence the authors (WC & KD) had used in prior studies (Corser and Dontje, 2011; Corser, Lein, Holmes-Rovner, & Gossain, 2010).
Before reading transcribed comments, the authors had decided that the most natural “unit of analysis” for these analyses was the individual participant. The following steps were used to analyze and categorize the entirety of interview comments:
- Each of the authors first independently read all transcribed interview comments several times, jotting down initial ideas regarding potential themes/sub-themes.
- Next, each author independently formulated a thematic outline of the core theme and sub-themes they had identified from interview data, later defending their draft outlines with exemplar quotes during team meetings.
- Each author then individually coded each interview comment and assigned their placement under a specific sub-theme, occasionally referring to interviewer field notes concerning individual participants without any a priori theme subtheme rules observed.
- Finally, the group reconvened to defend their respective comment placement decisions to the other authors. Differences were reviewed and discussed during an additional meeting until overall agreement was reached for assignment of codable interview comments.
Most comments were readily placed under a specific sub-theme, with 12 (5%) of comments initially judged to fall under two sub-themes. Approximately 10 (4%) comments regarding non-AVS topics were assessed to be un-codable and excluded from analyses.
The final analytic sample was comprised of 209 adult participants. The two research assistant authors who conducted the interviews estimated that fewer than 20 invited patients had decided to not participate. S.P.S.S. version 21 analytic software (I.B.M., 2012) was used to conduct all descriptive analyses. Ninety-four (45%) participants had received their primary care from the academic-based family medicine sample clinic, with the remaining 115 (55%) patients going to another nearby mid-Michigan community-based family medicine residency clinic.
Using a series of Chi-square and analysis of variance (ANOVA) procedures, the authors failed to find any statistically significant characteristic differences between participants from the two clinics in terms of age, sex, race or number of self-reported chronic health conditions. However, the participants from the community-based clinic were significantly more likely to be unmarried at time of interview (Pearson Chi-square = 10.824, p = 0.029), had completed less formal education (Pearson Chi-square= 37.988, p < 0.001) and were less interested in being contacted later for possible follow-up interviews (Pearson Chi-square = 7.365, p = 0.025).
The total participant sample reported an average age of 51 years (SD 15.55), ranging considerably from 21 to 83 years. 139 (66%) participants were females, and 151 (72%) reported their racial affiliation group as white. Particularly pertinent to health/eHealth literacy, 155 (74%) of all participants had completed some type of undergraduate or graduate college program, with 206 (98%) reporting English as their primary language spoken at home.
A total of 104 (50%) participants reported that they were currently married. 161 (77%) reported having at least one chronic health conditions (e.g. diabetes, heart disease, etc.) (Mean 1.77, SD 1.53). It was also determined that there was no significant relationship between whether participants making AVS suggestions were currently married (Pearson Chi-square = 5.078, p = 0.279), or the number of chronic health conditions they possessed. (Pearson Chi-square = 7.900, p = 0.341).
Modes of AVS Delivery
Unlike some American office visit settings, (Hummel and Evans, 2012; Neter and Brainin, 2012; Dontje, et. al., 2014), a higher proportion of 205 (98%) sample participants indicated that they had immediately received their AVS in paper form from a clinic staff member, with 119 (57%) of this number receiving their AVS directly from their nurse practitioner or physician. A subset of 125 (60%) participants reported that some type of healthcare provider had actually reviewed their AVS with them in some manner. A total of 98 (79%) participants initially thought that their problem list was at least “probably accurate.” Ninety-one participants (73%) indicated to their interviewer that their AVS medication list appeared “complete” and/or “up-to-date.”
Initial Participant AVS Assessments
A total of 110 (88%) participants initially responded that their AVS information “was easy to understand.” One specific concern identified by 125 (60%) participants was that they saw incorrect information concerning their allergies or medical history conditions listed. For example, only 51 (41%) of this subgroup reported that the “severity” of their prior allergic reactions had been correctly described. Approximately 166 (80%) participants stated that the information in the “Problems Addressed Today” AVS section initially made sense to them (if such information was actually entered), and 200 (96%) told interviewers that they could understood most listed AVS instructions.
Anticipated Use(s) of the AVS
Over 176 (86%) of participants could envision one or more specific future use(s) for their new office visit AVS. For the question, “What do you plan to do with your AVS?” raw responses were thematically collapsed into the three following overall themes: I. “File it” (without specific intent) (n = 88), II. “Keep it” (for a specific stated purpose) (n = 86), and III. “Throw it away/Nothing.” (n = 35)
Most comments made by the 88 (42%) “File it” category participants indicated that they would store their AVS somewhere at home, in their car or purse, etc. Another 86 (41%) participants expected that they would “Keep it” for a specific stated purpose, (e.g. “share with my son, other healthcare people,” “use for reference” or “review by myself at home”). Notably, 35 (17%) of all participants commented that they perceived no real value or future use for their AVS and would discard it. Of the 174 “File it” or “Keep it” participants, only 75 (43.1%) had one or more specific suggestion to make to improve the information on their AVS. This finding suggests that some participants may have been somewhat satisfied with their AVS for reference purposes, etc., while many other participants convey multiple concerns.
Suggestions for Improvement of the AVS
The primary focus of this paper is depicted in Table 1, summarizing the frequencies of comments placed to the question concerning participant’s AVS suggestions. First, a total of 118 (48%) participants indicated that they had no specific suggestions at all to make (Category V), although the interviewers had tried to afford them as much time as possible after reviewing their AVS. This finding suggests that the volume and/or complexity of health information listed on some AVS documents may have been imposing or difficult to comprehend.
The remaining 91 (44%) participants offered at least one suggestion or comment concerning the AVS. These 245 sample comments concerned varied, sometimes contradictory formatting and content preferences that the authors collapsed into four sub-themes: I. “Improve the format/layout of my AVS,” II. “Improve the clarity of my AVS,” III. “Correct discrepancies/omitted information,” and IV. “Provide my AVS in electronic form” (Table 1).
Most of the socio-demographic characteristics of those 91 participants who offered specific AVS suggestions were not significantly different from the rest of the sample. However, the 54 (26%) participants who had completed less than high school were significantly less likely to offer any specific AVS suggestions (Pearson Chi-square = 16.140, p= 0.003). The following section lists a series of exemplar quotes placed in quotation marksfor each thematic category and subcategory.
Theme I. Improve the Format/Layout of my AVS
Eleven (4.5% of total suggestions) participants suggested specific formatting/layout changes such as using colored graphics and larger print, bolding key words, creating clearer section headings, and/or organizing information in order of perceived importance.
“Larger print for those with eye trouble.”
“Use bold writing for drug names.”
Theme II.Improve the Clarity of my AVS
Forty-seven (19.2%) comments suggested changes such as using less medical terminology, providing only key health information and/or having an office healthcare provider personally review the AVS with them.
“At the top it says "keep to share with other providers"…… makes (me) think it is not important for me but rather more important for other doctors.”
IIa. Use Fewer Medical Terms
“Lots of medical terminology, use layman's terms."
“Use smaller words, there is too much writing/words for people to actually follow and comprehend.”
“I have a hard time understanding some medical terminology in problem list.”
IIb. Provide only Key Information
“Condense information. Use more bullets, make more visually understandable.”
“Make it more straightforward, only include ‘red flag’ information.”
IIc. Have Somebody Review This with Me
“Have nurses or doctors actually go over the paperwork and explain it before they send to you to check out.”
“Everyone should break it down and go slow, or have someone in the room to specifically go over the AVS.”
Theme III. Correct Incorrect/Missing Information
The largest proportion of all AVS suggestion comments (n = 61 or 24.9%) was assigned to this category concerning the clear frustrations some participants had with the information expected to be listed in certain AVS sections.
“’Problems addressed today’ left blank.”
“Says me and doctor discussed several things we did not actually discuss.”
IIIa. Allergies Section
" Not all allergies included as well as missing some reactions.”
“Allergies list says "severe", ……. can be subjective.”
IIIb. Medication List
“Shorten meds list to just new/added meds.”
“There is sometimes a discrepancy between what doc calls certain meds and what pharmacy names them.”
IIIc. Problem List
“Problems list section present but left blank.”
“Some conditions missing from problem list.”
“Remove old medical history, keep current problems.”
IIId. Provide me with Specific Instructions/ a “To Do” List
Fourteen of all AVS suggestion comments concerned an expectation for instructions that were more specific or some type of "To Do" list. The research assistants in both settings often found the AVS sections concerning patient instructions before the next office visit to be entirely empty.
“Instructions only say ‘follow up’, does not give specific medication instructions, treatments, to-do list, etc.”
“Useful to have vital signs and meds list, as well as what is needed to do next.”
Theme IV. Provide my AVS in Electronic Form
Nine (3.6%) of all comments suggested that office visit AVS be provided to patients in electronic form.
“Go paperless. Says web portal is very hard to navigate.”
“Send to email so can save to computer.”
These results indicate that there may be significant problems in how EHR-generated AVS documents are able to meet the needs of the primary care patients for the original purpose they were developed for to improve communication. Similar to several other studies (Parker and Wolf, 2015; Dontje, et. al., 2014; Beard, et. al., 2012), the authors subsequently discovered that the majority of sample participants had also already found it difficult/impossible to enter their own patient portals to update their health information or correct errors.
Anecdotally, it appeared that some clinic providers had experienced increased workload from allowing greater patient EHR permission settings to review and enter data, a similar finding to one earlier study (Emani, et al., 2014). This may be an excellent example of the numerous “social” dimensions of patient and provider use of informatics products shown to be prevalent in many rushed healthcare settings (Cucciniello, Lapsley, Nasi, & Pagliari, 2015; Dontje, et. al., 2014).
Our results certainly indicate that many office patients might prefer to have their AVS: a) limit their use of medical terminology, b) more clearly list actionable health information between their office visits, and c) provide more accurate complete data in the office visit AVS. This study demonstrates a considerable discrepancy between what the AVS had been first proposed to accomplish for primary care processes from what many participants in this generally well-educated English-speaking sample actually experienced.
It is certainly possible that some participants may have provided our interviewers with “preferred” or “socially desirable” responses for some interview questions. For example, 176 (84.2%) of all participants first responded “Yes” when asked “Is the AVS helpful to you?” although 113 (54.1%) interviewees later concluded that they would either file their AVS somewhere without a specific purpose or simply discard it. Similarly, although 184 (88.0%) participants initially responded that their AVS was “easy to understand” and “made general sense” to them, only 86 (46.7%) of this subgroup could later cite a specific reason for keeping their AVS.
Our finding that fewer than 10 (5%) of all participants anticipated that they would keep their AVS to share with other providers, use for medication reference purposes, etc., is also quite disheartening. The majority of the participants who could cite a specific use for their AVS also apparently expected to only use it for their personal reference needs, i.e. not to share with healthcare provider(s). This indicates that one of the original purposes of the AVS, sharing with other providers for increased communication, is not being met in this population.
These results should be reviewed within the context of several study limitations. The generalizability of our findings to other settings may be limited since we interviewed a relatively small convenience sample of quite homogenous primary care patients from two mid-Midwestern clinic settings. Another key reason that only 91 (43.5%) of our total sample participants offered any specific AVS suggestion comments may have been that they required more time to consider their responses. It is also apparent in other clinic settings that patients are routinely instructed to return to subsequent office visits with the prior AVS to help inform patient-provider discussions (Corepoint Health, 2016; Cucciniello, et. al., 2015).
Ideally, these pilot study results can be used to inform the more effective design and generation of AVS documents. It appears from these results that some of the AVS patient concerns could be resolved with two changes: one is revision of clinic provider practice patterns to review the summary with them, and the second is to work with the EHR designers to develop an AVS that is more relevant to the patient. A challenge in utilizing EHRs is that they are often designed without input from the end users, especially the patient. At the same time, the resources required to tailor the information and make sure it is updated could be especially difficult for primary care providers who are already overwhelmed with the need to enter quality data for reimbursement purposes (Heisey-Grove, Danehy, Consolazio, Lynch, & Mostsashari, 2014; Riddell, Sandford, Johnson, Steltenkamp, & Pearce, 2014). The cost of designing and implementing more eHealth-literate AVS module programs has already been shown to be considerable (Koh, et. al., 201; Koh, et. al., 2012; Heisey-Grove, et. al., 2014).
The fact that many of these AVS suggestions varied so considerably (e.g. “list more information” versus “condense information more”) may reflect the inherent complexity of developing healthcare informatics products to meet the varied preferences of office visit patients (Hummel and Evans, 2012; National Academy of Sciences, Engineering and Medicine, 2015; Pavlik, et. al., 2014). Future studies with more diverse providers including nursing and advanced practice nursing care patient samples to examine the potential of AVS to increase patient and patient-provider communications are acutely needed to maximize the longer-term effectiveness of such information tools (Neuberger, et. al., 2014; Sinsky, et. al., 2013; Heisey-Grove, et. al., 2014; D’Amore, Sittig, & Ness, 2012).
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Dr. William Corser, PhD, RN, NEA-BC, is the director of research at the Statewide Campus System in the Michigan State University (MSU) College of Osteopathic Medicine. His 2000 Ph.D. in nursing with a secondary concentration in population health research is from the University of Wisconsin-Madison. Bill’s program of health services research has generally focused on the major predictive influences of health information technology-related outcomes of heavily comorbid and chronically ill adults. As a former nurse manager and administrator, he has consulted for numerous Midwest healthcare systems in the areas of research and quality improvement project design and methods. Bill has over 75 peer-reviewed publications to date with funding for over 30 projects from the Agency of Healthcare Research and Quality (AHRQ), Sigma Theta Tau International and state governments/foundations.
Dr. Kathy Dontje, FNP-BC, FAANP, is a practicing family nurse practitioner and current director of the Doctor of Nursing Practice Program at the MSU College of Nursing. Her 2009 Ph.D. from the University of Wisconsin-Michigan concerned the use of standardized EHR terminology to support evidence-based practices for patients with depressive symptoms.
Ms. Marolee Neuberger, MS, is director of the MSU Family Medicine Residency Program. As a health literacy specialist, Marolee’s research program has focused on primary care patients’ perspectives on EHR and other informatics tools.
Ms Erika Chant, BS, currently serves as a mid-Michigan primary care office manager and served as one of two research assistants for this project.
Ms. Abigail Keskimaki, MPH, is currently an infection control practitioner at Henry Ford Health System in Detroit, Mich., and served as one of two research assistants for this project.