Author Archives: Zuzanna Walter

Open Notes: Patient Transparency and the New Federal Mandate

October 28, 2020

Alongside a surge in telemedicine adoption and increasing reliance on technology, the growing shift to digital healthcare delivery has prompted a cultural shift in medicine forcing many clinicians to abandon the traditional model in favor of a more modern approach. An elemental component of the modern medical care model is patient transparency, which has been at the forefront of discussions in recent weeks due to the forthcoming implementation of a new federal mandate.

To support universal patient transparency, beginning November 2, 2020 all patients in the United States will have immediate access to clinical notes and thus, will be able to read and review clinician’s writings, test results, and other health reports. Per the 21st Century Cures Act systems need to “support patients’ access to their EHI in a form convenient for patients, such as making a patient’s EHI more electronically accessible through the adoption of standards and certification criteria and the implementation of information blocking policies that support patient electronic access to their health information at no cost.”

Open Notes Policy 

Referred to commonly as “open notes”, the new federal mandate requires the release of all inpatient and outpatient notes for immediate patient access, including test results with potentially sensitive information. The information now made available to patients immediately includes consultation notes, discharge summaries, medical history, physical examination findings, imaging narratives, laboratory and pathology report narratives, and procedure and progress notes. Unsurprisingly, the plan has been widely contested by healthcare professionals who fear it will result in increased workloads and adverse patients reactions. However, there has been a growing adoption of the new protocols with time as evidenced by several institutions which have already implemented the policy.

Those supporting the new law believe it has the potential to strengthen patient-provider communication and relationships. Certain healthcare institutions are ahead of the curve; UC Davis Health voluntarily implemented open notes a year ago although only two dozen of 1,000 staff physicians opted into the program. Nonetheless, those that did reported positive results and support for the initiative. Similarly, at the University of Colorado Cancer Center, open access to oncology notes has been granted to patients for the past 5 years with no reported issues and highly appreciated by patients.

Sensitive Health Information 

Sensitive information may present more of an issue in certain specialties, such as oncology, psychiatry, genetics, and adolescent medicine. For instance, when reading pathology or imaging notes, patients may learn they have been diagnosed with cancer without a physician’s explanation or contextualization. In oncology specifically, patients may struggle to understand their prognosis and treatment plan leaving them stressed, frightened, and/or confused. In certain cases, the importance of physician contact and empathy may be much needed and more valuable than previously thought.

Medical professionals highlight the importance of clear, open, and honest communication with their patients to better accommodate the forthcoming open notes protocols. “When I order imaging or send pathology specimens, I have already discussed with the patient the possibilities, including cancer, and what we will do next. Patients deeply appreciate these discussions, before they see the results,” Dr. Robert Breeze, vice-chair of neurosurgery at UCHealth in Anschutz, Colorado told Medscape in an interview.

As clinicians tend to write notes in medical lexicon, they may now need to write things out in lay terms for the benefit of their patients which may potentially generate more work. Although the new mandate does not require a change in writing style, many clinicians may find they will need to alter their notes to make them more readable for patients, potentially making them less useful for utilization review, billing, and other internal purposes.

Clinicians in favor believe that the open notes policy will help serve overworked physicians by empowering their patients, allowing them to better understand their treatment plan and medication which can ultimately minimize the physician’s workload. Although the federal mandate may seem daunting, the benefits may outweigh the risks if notes are compiled in a patient-focused manner in line with a patient-centered care model. Access to clinical notes, results, and other important health information may promote patient engagement and treatment adherence, as well as deepen the patient-provider relationship.

Psychiatric Disorders and COVID-19 Mortality Rates, Outcomes

October 21, 2020

Psychiatric disorders have a documented association with lower life expectancy – in some cases shortening lifespan by as much as 10 years – as well as increased risk of comorbid medical conditions. In light of the persisting COVID-19 public health crisis, experts are concerned that psychiatric comorbidity may increase virus-related mortality and predispose patients to poorer outcomes.

Ongoing and emerging research efforts aim to investigate the implications of prior psychiatric diagnoses on COVID-19-related mortality and health outcomes. According to data from a recent Yale University study, patients suffering from mental illnesses may face a higher risk for severe COVID-19 outcomes including death.

Psychiatric Comorbidity and COVID-19 Mortality


Researchers from the Yale University School of Medicine evaluated data obtained from the Yale New Haven Health System. Overall, the study included clinical data from 1,685 patients hospitalized with COVID-19 infection between February 15 and April 25, 2020.

Within that cohort, those who had been diagnosed with prior psychiatric disorders had a significantly elevated mortality risk compared with patients without a diagnosis after controlling for demographic characteristics, comorbidities, and hospital location. Of the 1,685 total participants, 473 (28%) received psychiatric diagnoses prior to hospitalization. This group was significantly older and more likely to be female, non-Hispanic white, and to have medical comorbidities. Overall, 318 patients or nearly 19% of the cohort died. The highest risk for COVID-19 mortality was reported among patients with a psychiatric diagnoses at 2 weeks after their index hospitalization, as well as at 3 and 4 weeks.

South Korean Cohort Study

In a similar study conducted by South Korean researchers, a cohort of patients with mental illness did not have an increased risk for testing positive for COVID-19 compared with the general population. However, the findings, published in Lancet Psychiatry, reveal that patients with a severe mental illness diagnosis had a greater risk of severe COVID-19 outcomes – including death, intensive care unit admission, and use of mechanical ventilation.

In this study cohort, groups with and without mental illness were matched demographically and by the presence of comorbid conditions.

Association Between Psychiatric Diagnosis and COVID-19 Outcomes

The latest studies are the first to characterize the association of psychiatric diagnosis with COVID-19 mortality. Their findings are similar to previous scientific results, confirming that individuals with comorbid psychiatric and medical diagnoses had poorer outcomes and higher mortality rates. However, the reasons underlying this association remain unclear at this time.

“Psychiatric symptoms may arise as a marker of systemic pathophysiologic processes, such as inflammation, that may, in turn, predispose to mortality,” the U.S. study’s authors wrote in the research letter. “Similarly, psychiatric disorders may augment systemic inflammation and compromise the function of the immune system, while psychotropic medications may also be associated with mortality risk.”

The Yale University study’s authors acknowledged their trial’s limitations, including the fact that individuals not hospitalized for COVID-19 as well as those who died outside of the hospital were not included in the dataset. Furthermore, diagnosis codes were used to determine psychiatric diagnosis, which do not account for the status of treatment or whether the patient had an active, in-remission, or recovered psychiatric disorder in both of the studies.

Neither study took obesity or cigarette smoking into account, nor socioeconomic status or patient education level, which may be confounding factors.

Medical experts believe that an underlying biological mechanism related to the immune system may provide an explanation for this association although, further research is needed to confirm.

The author’s stress the importance of the consequences of mental illness as related to poorer health and decreased life expectancy, which may be in part due to reduced access to medical care and treatment adherence. Many individuals with psychiatric disorders lack health insurance or adequate coverage which may delay them seeking medical care; these patients may present at the hospital with more advanced stages of COVID-19. Clinicians should take these factors into consideration when treating patients with COVID-19 and remain aware of the multifactorial risks associated with pre-existing mental illness. 

Most Effective Strategies for Optimizing Patient Engagement

October 15, 2020

There is a growing recognition of the importance of patient engagement as the key component of high-performing, cost-efficient healthcare systems which increase treatment adherence and self-monitoring as well as improve population health outcomes. Healthcare organizations who prioritize a strong team-based care infrastructure are better positioned to optimize patient engagement programming – broadly defined as the process of actively involving patients in their care and treatment decisions.

New research reveals that it is a relationship-based approach that builds trust and promotes patient autonomy, while organizational and administrative factors provide the foundation for such patient engagement. Organizations and health systems with provider champions, clear-cut staff duties, team performance improvement meetings, and staff dedicated to patient engagement tend to be more successful, according to findings published in the Annals of Family Medicine.

Optimizing Patient Engagement 

The recent study aimed to identify specific organizational factors that were associated with a greater adoption of patient engagement care practices within Veterans Health Administration (VA) primary care clinics. At these locations, patient engagement efforts were centered on the Patient-Aligned Care Team (PACT) initiative, which leverages aspects of the patient-centered medical home model to deliver comprehensive and continuous team-based care to veterans.

Investigators evaluated the adoption of PACT protocols across the VA primary care clinic system by analyzing responses from a survey completed by 2,500 clinicians at over 600 locations across the nation. Their results revealed that respondents at high-performing clinics were more likely to report regular team meetings aimed at discussing performance improvement and dedicated leadership responsible for the implementation of PACT best practices. High performance was also associated with fully-staffed PACT teams and clearly defined staff roles.

Overall, healthcare organizations only modestly implemented the recommended patient engagement tactics as results indicated a significantly lowered adoption of motivational interviewing and self-management programming.

“Lower use of these practices may be related to clinicians’ perceptions that some elements of the patient-centered medical home may not be entirely relevant (or may be difficult to use) for particular groups of patients during visits,” the researchers explained.

Organizational Factors

Revealing the importance of organizational elements, the study emphasizes the need to create new patient-centered relationships – that were found most effective for promoting patient engagement among high-performing clinics.

“Team-based care is a key driver of the use of patient engagement care processes and may directly affect patients’ level of engagement,” the study’s authors wrote. “Factors related to patients, team members, and workload may moderate the influence of team-based care on use of patient engagement care processes.”

Clear staffing roles were tied to better adherence to PACT, including motivational interviewing and organizational programming. Team-based huddles were essential for communicating quality improvement data: “Improved team collaboration and coordination are necessary for practices to manage the increasing complexity and unpredictability of clinical care and to become more accountable for patient-centered outcomes,” the authors concluded.

Next Steps

The latest findings emphasize the need to prioritize organizational elements of healthcare practices  and organizations in order to deliver care and achieve optimized patient engagement. Promoting fully-staffed facilities, identifying clearly defined roles of team members, more effective leadership, and a practice culture of performance improvement all may increase the efficacy of patient engagement initiatives and subsequently patient health outcomes.

While the team of researchers continues to examine the specific aspects of the patient-centered medical home model that most effectively improve engagement, the outlined organizational elements can be improved to better the functionality of primary care teams and enhance patient engagement in the medical care process.