JMIR Publications

ABSTRACT

Background:

Online record access (ORA) is being increasingly implemented internationally. Despite reported benefits for patients, health care professionals (HCPs) have raised concerns about potential disadvantages. To date, no review has examined the empirical evidence on whether and how documentation changes following the introduction of patients’ ORA.

Objective:

This scoping review examines potential subjective and objective changes in HCPs documentation after using patients’ ORA.

Methods:

A scoping review based on Arksey and O’Malley’s framework was conducted using 4 electronic databases. Studies that focused on objective and subjective changes in clinical documentation after the implementation of ORA and related to actual experience of use (not just prior expectations about ORA) up to July 2023 were included. The Mixed Methods Appraisal Tool was used to assess the quality of the included studies. The PRISMA Extension for Scoping Reviews guided the narrative synthesis and reporting of findings.

Results:

Of the 3143 papers screened, 42 were included in this review. The included studies mainly used qualitative methods and were predominantly published after 2016 in the United States. The included studies were conducted in different settings (inpatient and outpatient) and clinical areas (somatic, mental health, other). 8 studies analyzed clinical notes, while the remaining studies focused on the experiences of patients, HCPs and other stakeholders with ORA. Objectively, a decrease in complexity, an increase in readability, and a change in the emotional tone of the clinical notes were observed. The length of the clinical notes was observed to change both objectively and subjectively, although the direction of this change was inconclusive. However, many HCPs also report writing notes that are less open and more restrictive in order to protect sensitive or hypothetical information. While for some HCPs the implementation of ORA made the clinical notes a less efficient and valuable working tool, others perceived that ORA opened up new therapeutic opportunities through direct contact with patients.

Conclusions:

The question of whether an inherently uniform clinical note can meet the diverse needs of the different healthcare stakeholders remains unresolved, highlighting the challenges of standardizing practices in this complex sector. While ORA may encourage HCPs to make their clinical notes more patient-friendly, it may also compromise the integrity of documentation by omitting sensitive findings and expert judgment, which can put patients at risk and lead to errors that increase the risk of malpractice. Given the limitations of digital documentation in fostering trust, it is imperative to prioritize meaningful patient-provider interactions. The use of compensatory measures, such as parallel documentation and restricted access to clinical notes, indicates systemic problems and suggests that current practices are suboptimal.