JMIR Publications

ABSTRACT

Background:

Internationally, patient-accessible electronic health records (PAEHRs) are increasingly being implemented. Beyond reported benefits to patients, the innovation has prompted concerns among health care professionals (HCPs), including the possibility that access incurs a ‘dumbing down’ of clinical records. Currently no review has investigated empirical evidence of whether and how documentation changes after introducing PAEHRs.

Objective:

This paper presents the protocol for a scoping review examining potential subjective and objective changes in HCPs documentation after using PAEHRs.

Methods:

This scoping review will be carried out based on the framework of Arksey and O’Malley. Several databases will be used to conduct a literature search (APA PsycInfo, CINAHL, PubMed, Web of Science Core Collection). Authors will participate in screening identified papers, to explore the research questions: How do PAEHRs affect HCPs documentation practices? What subjective and objective changes to the clinical notes arise after patient access? Only studies that relate to actual usage experiences, and not merely prior expectations about PAEHRs, will be selected in the review. Data abstraction will include but will not be limited to publication type, publication year, country, sample characteristics, setting, study aim, research question, and conclusions. The Mixed Methods Appraisal Tool will be used to assess the quality of the studies included.

Results:

The results from this scoping review will be presented as a narrative synthesis structured along the key themes of the corpus of evidence. Additional data will be prepared in charts or tabular format. This scoping review protocol was first initiated by Uppsala University in collaboration with Brandenburg Medical School in January 2023. The results are expected to be presented in a scoping review in July 2023. They will be disseminated at scientific conferences and through publication in a peer-reviewed journal.

Conclusions:

To our knowledge, this is the first scoping review that will address potential change in documentation after implementation of PAEHRs. The results can potentially help affirm or refute prior opinions and expectations among various stakeholders about the use of PAEHRs and thereby help to address uncertainties. They may help to provide guidance to clinicians in writing notes and thus have immediate practical relevance to care. In addition, the review will help to identify any substantive research gaps in this field of research. In the longer term, our findings may contribute to the development of shared documentation guidelines, which in turn are central to improving patient communication and safety.