Barriers to Esketamine Nasal Spray Treatment Among Adults With Treatment-Resistant Depression.

Background: Under a risk evaluation and mitigation strategy program, esketamine nasal spray CIII requires self administration at a certified treatment center. Our objective was to identify factors associated with esketamine initiation and continuation.Methods: A retrospective observational cohort study was conducted among US adults who met treatment-resistant depression (TRD) criteria. Cases (n = 966) initiated esketamine between October 11, 2019, and February 28, 2022, and were compared to controls (n = 39,219) with TRD but no esketamine use. Outcomes included initiation, induction (8 administrations within 45 days), and interruptions (30-day treatment gap). Comorbid psychiatric conditions were identified using International Classification of Diseases, Tenth Revision, Clinical Modification, codes.Results: Cases resided significantly closer to treatment centers (8.9 vs 20.3 miles). Compared to 0-9 miles, initiation rate decreased by 11.9%, 50.8%, 68.1%, 75.9%, and 92.8% for individuals residing 10-19, 20-29, 30-39, 40-49, and 50+ miles from a center. After adjustment, factors associated with increased likelihood of initiation were posttraumatic stress disorder, major depressive disorder with suicidal ideation, and male sex, while increasing distance, substance use disorder, Medicaid, Charlson Comorbidity Index (CCI), and older age were associated with lower likelihood. Factors associated with lower likelihood of completing induction were Medicaid, low socioeconomic status (SES), CCI, and Hispanic communities. Factors associated with increased likelihood of interruption were alcohol use disorder, distance, and minority communities, while generalized anxiety disorder and Medicaid were associated with lower likelihood.Conclusions: Travel distance, insurance, low SES, and minority communities are potential barriers to treatment. Alternative care models may be needed to ensure adequate access to care.J Clin Psychiatry 2024;85(2):23m15102.

A Practical Approach to Predicting Surgical Site Infection Risk Among Patients Before Leaving the Operating Room.

A surgical site infection (SSI) prediction model that identifies at-risk patients before leaving the operating room can support efforts to improve patient safety. In this study, eight pre-operative and five perioperative patient- and procedure-specific characteristics were tested with two scoring algorithms: 1) count of positive factors (manual), and 2) logistic regression model (automated). Models were developed and validated using data from 3,440 general and oncologic surgical patients. In the automated algorithm, two pre-operative (procedure urgency, odds ratio [OR]: 1.7; and antibiotic administration >2 hours before incision, OR: 1.6) and three intraoperative risk factors (open surgery [OR: 3.7], high-risk procedure [OR: 3.5], and operative time OR: [2.6]) were associated with SSI risk. The manual score achieved an area under the curve (AUC) of 0.831 and the automated algorithm achieved AUC of 0.868. Open surgery had the greatest impact on prediction, followed by procedure risk, operative time, and procedure urgency. At 80% sensitivity, the manual and automated scores achieved a positive predictive value of 16.3% and 22.0%, respectively. Both the manual and automated SSI risk prediction algorithms accurately identified at-risk populations. Use of either model before the patient leaves the operating room can provide the clinical team with evidence-based guidance to consider proactive intervention to prevent SSIs.

SuperOrder: Provider order recommendation system for outpatient clinics.

This study aims at developing SuperOrder, an order recommendation system for outpatient clinics. Using the electronic health record data available at midnight, SuperOrder predicts the order contents for each upcoming appointment on a daily basis. A two-level prediction framework is proposed. At the base-level, the predictions are produced by aggregating three machine learning methods. The meta-level predictions are generated by integrating the base-level predictions with the order co-occurrence network. We used the retrospective data between 1 April 2014 and 31 March 2015 in pulmonary clinics from five hospital sites within a large rural health care facility in Pennsylvania to test the feasibility. With a decrease of 6 per cent in the precision, the improvement of the recall at the meta-level is approximately 20 per cent from the base-level. This demonstrates that the proposed order co-occurrence network helps in increasing the performance of order predictions. The implementation will bring a more effective and efficient way to place outpatient orders.

When doctors share visit notes with patients: a study of patient and doctor perceptions of documentation errors, safety opportunities and the patient-doctor relationship.

BACKGROUND: Patient advocates and safety experts encourage adoption of transparent health records, but sceptics worry that shared notes may offend patients, erode trust or promote defensive medicine. As electronic health records disseminate, such disparate views fuel policy debates about risks and benefits of sharing visit notes with patients through portals. METHODS: Presurveys and postsurveys from 99 volunteer doctors at three US sites who participated in OpenNotes and postsurveys from 4592 patients who read at least one note and submitted a survey. RESULTS: Patients read notes to be better informed and because they were curious; about a third read them to check accuracy. In total, 7% (331) of patients reported contacting their doctor's office about their note. Of these, 29% perceived an error, and 85% were satisfied with its resolution. Nearly all patients reported feeling better (37%) or the same (62%) about their doctor. Patients who were older (>63), male, non-white, had fair/poor self-reported health or had less formal education were more likely to report feeling better about their doctor. Among doctors, 26% anticipated documentation errors, and 44% thought patients would disagree with notes. After a year, 53% believed patient satisfaction increased, and 51% thought patients trusted them more. None reported ordering more tests or referrals. CONCLUSIONS: Despite concerns about errors, offending language or defensive practice, transparent notes overall did not harm the patient-doctor relationship. Rather, doctors and patients perceived relational benefits. Traditionally more vulnerable populations-non-white, those with poorer self-reported health and those with fewer years of formal education-may be particularly likely to feel better about their doctor after reading their notes. Further informing debate about OpenNotes, the findings suggest transparent records may improve patient satisfaction, trust and safety.

Inviting patients and care partners to read doctors' notes: OpenNotes and shared access to electronic medical records.

We examined the acceptability and effects of delivering doctors' visit notes electronically (via OpenNotes) to patients and care partners with authorized access to patients' electronic medical records. Adult patients and care partners at Geisinger Health System were surveyed at baseline and after 12 months of exposure to OpenNotes. Reporting on care partner access to OpenNotes, patients and care partners stated that they had better agreement about patient treatment plans and more productive discussions about their care. At follow-up, patients were more confident in their ability to manage their health, felt better prepared for office visits, and reported understanding their care better than at baseline. Care partners were more likely to access and use patient portal functionality and reported improved communication with patients' providers at follow-up. Our findings suggest that offering patients and care partners access to doctors' notes is acceptable and improves communication and patients' confidence in managing their care.

Predicting Patients at Risk for 3-Day Postdischarge Readmissions, ED Visits, and Deaths.

BACKGROUND: Transitional care interventions can be utilized to reduce post-hospital discharge adverse events (AEs). However, no methodology exists to effectively identify high-risk patients of any disease across multiple hospital sites and patient populations for short-term postdischarge AEs. OBJECTIVES: To develop and validate a 3-day (72 h) AEs prediction model using electronic health records data available at the time of an indexed discharge. RESEARCH DESIGN: Retrospective cohort study of admissions between June 2012 and June 2014. SUBJECTS: All adult inpatient admissions (excluding in-hospital deaths) from a large multicenter hospital system. MEASURES: All-cause 3-day unplanned readmissions, emergency department (ED) visits, and deaths (REDD). The REDD model was developed using clinical, administrative, and socioeconomic data, with data preprocessing steps and stacked classification. Patients were divided randomly into training (66.7%), and testing (33.3%) cohorts to avoid overfitting. RESULTS: The derivation cohort comprised of 64,252 admissions, of which 2782 (4.3%) admissions resulted in 3-day AEs and 13,372 (20.8%) in 30-day AEs. The c-statistic (also known as area under the receiver operating characteristic curve) of 3-day REDD model was 0.671 and 0.664 for the derivation and validation cohort, respectively. The c-statistic of 30-day REDD model was 0.713 and 0.711 for the derivation and validation cohort, respectively. CONCLUSIONS: The 3-day REDD model predicts high-risk patients with fair discriminative power. The discriminative power of the 30-day REDD model is also better than the previously reported models under similar settings. The 3-day REDD model has been implemented and is being used to identify patients at risk for AEs.

Patients, care partners, and shared access to the patient portal: online practices at an integrated health system.

OBJECTIVE: To describe the characteristics and online practices of patients and "care partners" who share explicit access to a patient portal account at a large integrated health system that implemented shared access functionality in 2003. MATERIALS AND METHODS: Survey of 323 patients and 389 care partners at Geisinger Health System with linked information regarding access and use of patient portal functionality. RESULTS: Few (0.4%) registered adult patient portal users shared access to their account. Patients varied in age (range: 18-102); more than half had a high school education or less (53.6%). Patient motivations for sharing access included: to help manage care (41.9%), for emergency reasons (29.7%), lack of technology experience (18.4%), or care partner request (10.0%). Care partners were parents (39.8%), adult children (27.9%), spouses (26.2%), and other relatives (6.1%). Patients were more likely than care partners to have inadequate health literacy (54.8% versus 8.8%, P < .001) and less confident in their ability to manage their care (53.0% versus 88.1%; P < .001). Care partners were more likely than patients to perform health management activities electronically (95.5% versus 48.4%; P < .001), access the patient portal (89.2% versus 30.3%; P < .001), and use patient portal functionality such as secure messaging (39.6% versus 13.9%; P < .001). Care partners used their own credentials (89.1%) and patient credentials (23.3%) to access the patient portal. DISCUSSION AND CONCLUSION: Shared access is an underused strategy that may bridge patients' health literacy deficits and lack of technology experience and that helps but does not fully resolve concerns regarding patient and care partner identity credentials.

Family Caregivers and Consumer Health Information Technology.

Health information technology has been embraced as a strategy to facilitate patients' access to their health information and engagement in care. However, not all patients are able to access, or are capable of using, a computer or mobile device. Although family caregivers assist individuals with some of the most challenging and costly health needs, their role in health information technology is largely undefined and poorly understood. This perspective discusses challenges and opportunities of engaging family caregivers through the use of consumer-oriented health information technology. We compile existing evidence to make the case that involving family caregivers in health information technology as desired by patients is technically feasible and consistent with the principles of patient-centered and family-centered care. We discuss how more explicit and purposeful engagement of family caregivers in health information technology could advance clinical quality and patient safety by increasing the transparency, accuracy, and comprehensiveness of patient health information across settings of care. Finally, we describe how clarifying and executing patients' desires to involve family members or friends through health information technology would provide family caregivers greater legitimacy, convenience, and timeliness in health system interactions, and facilitate stronger partnerships between patients, family caregivers, and health care professionals.

Assessing the Quality of Death and Dying in an Integrated Health Care System in Rural Pennsylvania.

CONTEXT: With growing emphasis on improving the value of health care, there is increased scrutiny of quality outcomes and high health expenditures during the final months of life. OBJECTIVES: The purpose of this project is to answer 1) how do next of kin (NOK) perceive the quality of their loved ones' dying and death; 2) are there patient and NOK characteristics that predict lower quality; and 3) are there structural aspects of care associated with lower quality? METHODS: A mailed survey was administered to a stratified random sample of NOK of Geisinger Health System patients who had died in the past year. The Quality of Death and Dying, the General Anxiety Disorder seven-item scale, the Patient Health Questionnaire eight-item depression scale, and selected questions from the Toolkit of Instruments to Measure End of Life Care were used. RESULTS: There were 672 respondents. Significant predictors of Quality of Death and Dying score were number of doctors involved in care (P = 0.0415), location of death (P < 0.0001), frequency of receiving confusing or contradictory information (P < 0.0001), illness progression (P = 0.0343), Patient Health Questionnaire-2 score (P = 0.0148), and General Anxiety Disorder seven-item scale score (P < 0.0070). CONCLUSION: Several findings suggest that factors such as NOK depression and anxiety, prolonged illness, dying in the hospital, receipt of conflicting information, and confusion around the doctor in charge are associated with lower quality of the dying and death experience for NOK. Further investigation is warranted to facilitate high-quality measurement and the use of measurement results to improve care.

Patients who share transparent visit notes with others: characteristics, risks, and benefits.

BACKGROUND: Inviting 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. OBJECTIVE: Our 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. METHODS: The 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. RESULTS: More 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. CONCLUSIONS: One 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.

Family experience with intensive care unit care: association of self-reported family conferences and family satisfaction.

PURPOSE: A family conference is recommended as a best practice to improve communication in the intensive care unit (ICU), but this can be challenging given the setting. This study examined whether family members who reported that a family conference occurred had higher satisfaction than those who did not report that a conference was held. MATERIALS AND METHODS: The study used a retrospective data analysis of family satisfaction based on family member's responses to a questionnaire. Families of all the patients admitted to ICUs of 2 quaternary hospitals in an integrated health system were surveyed. RESULTS: The families of 457 patients who matched the inclusion and exclusion criteria were surveyed with a 55.6% response rate. Family satisfaction with decision making was significantly higher (83.6 vs 78.2, P=.0211) for families who reported that family conferences occurred. No significant difference in the satisfaction with care and overall satisfaction scores was found (84.2 vs 80.0, P=.10). Patients whose families reported a family conference were older and had higher mortality. CONCLUSION: This study confirms that families who report attending family conferences are more satisfied with decision making in the ICU. This study highlights the need to increase communication in ICUs.

Online access to doctors' notes: patient concerns about privacy.

BACKGROUND: Offering 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. OBJECTIVE: To identify patients' attitudes toward privacy when given electronic access to their medical records, including visit notes. METHODS: The 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. RESULTS: 32.91% 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. CONCLUSIONS: When 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.

Beyond the threshold: real-time use of evidence in practice.

In two landmark reports on Quality and Information Technology, the Institute of Medicine described a 21st century healthcare delivery system that would improve the quality of care while reducing its costs. To achieve the improvements envisioned in these reports, it is necessary to increase the efficiency and effectiveness of the clinical decision support that is delivered to clinicians through electronic health records at the point of care. To make these dramatic improvements will require significant changes to the way in which clinical practice guidelines are developed, incorporated into existing electronic health records (EHR), and integrated into clinicians' workflow at the point of care. In this paper, we: 1) discuss the challenges associated with translating evidence to practice; 2) consider what it will take to bridge the gap between the current limits to use of CPGs and expectations for their meaningful use at the point of care in practices with EHRs; 3) describe a framework that underlies CDS systems which, if incorporated in the development of CPGs, can be a means to bridge this gap, 4) review the general types and adoption of current CDS systems, and 5) describe how the adoption of EHRs and related technologies will directly influence the content and form of CPGs. Achieving these objectives should result in improvements in the quality and reductions in the cost of healthcare, both of which are necessary to ensure a 21st century delivery system that consistently provides safe and effective care to all patients.

Inviting patients to read their doctors' notes: a quasi-experimental study and a look ahead.

BACKGROUND: Little information exists about what primary care physicians (PCPs) and patients experience if patients are invited to read their doctors' office notes. OBJECTIVE: To evaluate the effect on doctors and patients of facilitating patient access to visit notes over secure Internet portals. DESIGN: Quasi-experimental trial of PCPs and patient volunteers in a year-long program that provided patients with electronic links to their doctors' notes. SETTING: Primary care practices at Beth Israel Deaconess Medical Center (BIDMC) in Massachusetts, Geisinger Health System (GHS) in Pennsylvania, and Harborview Medical Center (HMC) in Washington. PARTICIPANTS: 105 PCPs and 13,564 of their patients who had at least 1 completed note available during the intervention period. MEASUREMENTS: Portal use and electronic messaging by patients and surveys focusing on participants' perceptions of behaviors, benefits, and negative consequences. RESULTS: 11,155 [corrected] of 13,564 patients with visit notes available opened at least 1 note (84% at BIDMC, 82% [corrected] at GHS, and 47% at HMC). Of 5219 [corrected] patients who opened at least 1 note and completed a postintervention survey, 77% to 59% [corrected] across the 3 sites reported that open notes helped them feel more in control of their care; 60% to 78% of those taking medications reported increased medication adherence; 26% to 36% had privacy concerns; 1% to 8% reported that the notes caused confusion, worry, or offense; and 20% to 42% reported sharing notes with others. The volume of electronic messages from patients did not change. After the intervention, few doctors reported longer visits (0% to 5%) or more time addressing patients' questions outside of visits (0% to 8%), with practice size having little effect; 3% to 36% of doctors reported changing documentation content; and 0% to 21% reported taking more time writing notes. Looking ahead, 59% to 62% of patients believed that they should be able to add comments to a doctor's note. One out of 3 patients believed that they should be able to approve the notes' contents, but 85% to 96% of doctors did not agree. At the end of the experimental period, 99% of patients wanted open notes to continue and no doctor elected to stop. LIMITATIONS: Only 3 geographic areas were represented, and most participants were experienced in using portals. Doctors volunteering to participate and patients using portals and completing surveys may tend to offer favorable feedback, and the response rate of the patient surveys (41%) may further limit generalizability. CONCLUSION: Patients accessed visit notes frequently, a large majority reported clinically relevant benefits and minimal concerns, and virtually all patients wanted the practice to continue. With doctors experiencing no more than a modest effect on their work lives, open notes seem worthy of widespread adoption. PRIMARY FUNDING SOURCE: The Robert Wood Johnson Foundation, the Drane Family Fund, the Richard and Florence Koplow Charitable Foundation, and the National Cancer Institute.

Inviting patients to read their doctors' notes: patients and doctors look ahead: patient and physician surveys.

BACKGROUND: Little is known about what primary care physicians (PCPs) and patients would expect if patients were invited to read their doctors' office notes. OBJECTIVE: To explore attitudes toward potential benefits or harms if PCPs offered patients ready access to visit notes. DESIGN: The PCPs and patients completed surveys before joining a voluntary program that provided electronic links to doctors' notes. SETTING: Primary care practices in 3 U.S. states. PARTICIPANTS: Participating and nonparticipating PCPs and adult patients at primary care practices in Massachusetts, Pennsylvania, and Washington. MEASUREMENTS: Doctors' and patients' attitudes toward and expectations of open visit notes, their ideas about the potential benefits and risks, and demographic characteristics. RESULTS: 110 of 114 participating PCPs (96%), 63 of 140 nonparticipating PCPs (45%), and 37 856 of 90 203 patients (42%) completed surveys. Overall, 69% to 81% of participating PCPs across the 3 sites and 92% to 97% of patients thought open visit notes were a good idea, compared with 16% to 33% of nonparticipating PCPs. Similarly, participating PCPs and patients generally agreed with statements about potential benefits of open visit notes, whereas nonparticipating PCPs were less likely to agree. Among participating PCPs, 74% to 92% anticipated improved communication and patient education, in contrast to 45% to 67% of nonparticipating PCPs. More than one half of participating PCPs (50% to 58%) and most nonparticipating PCPs (88% to 92%) expected that open visit notes would result in greater worry among patients; far fewer patients concurred (12% to 16%). Thirty-six percent to 50% of participating PCPs and 83% to 84% of nonparticipating PCPs anticipated more patient questions between visits. Few PCPs (0% to 33%) anticipated increased risk for lawsuits. Patient enthusiasm extended across age, education, and health status, and 22% anticipated sharing visit notes with others, including other doctors. LIMITATIONS: Access to electronic patient portals is not widespread, and participation was limited to patients using such portals. Response rates were higher among participating PCPs than nonparticipating PCPs; many participating PCPs had small patient panels. CONCLUSION: Among PCPs, opinions about open visit notes varied widely in terms of predicting the effect on their practices and benefits for patients. In contrast, patients expressed considerable enthusiasm and few fears, anticipating both improved understanding and more involvement in care. Sharing visit notes has broad implications for quality of care, privacy, and shared accountability. PRIMARY FUNDING SOURCE: The Robert Wood Johnson Foundation's Pioneer Portfolio, Drane Family Fund, and Koplow Charitable Foundation.

Determining correspondences between high-frequency MedDRA concepts and SNOMED: a case study.

BACKGROUND: The Systematic Nomenclature of Medicine Clinical Terms (SNOMED CT) is being advocated as the foundation for encoding clinical documentation. While the electronic medical record is likely to play a critical role in pharmacovigilance - the detection of adverse events due to medications - classification and reporting of Adverse Events is currently based on the Medical Dictionary of Regulatory Activities (MedDRA). Complete and high-quality MedDRA-to-SNOMED CT mappings can therefore facilitate pharmacovigilance. The existing mappings, as determined through the Unified Medical Language System (UMLS), are partial, and record only one-to-one correspondences even though SNOMED CT can be used compositionally. Efforts to map previously unmapped MedDRA concepts would be most productive if focused on concepts that occur frequently in actual adverse event data. We aimed to identify aspects of MedDRA that complicate mapping to SNOMED CT, determine pattern in unmapped high-frequency MedDRA concepts, and to identify types of integration errors in the mapping of MedDRA to UMLS. METHODS: Using one years' data from the US Federal Drug Administrations Adverse Event Reporting System, we identified MedDRA preferred terms that collectively accounted for 95% of both Adverse Events and Therapeutic Indications records. After eliminating those already mapping to SNOMED CT, we attempted to map the remaining 645 Adverse-Event and 141 Therapeutic-Indications preferred terms with software assistance. RESULTS: All but 46 Adverse-Event and 7 Therapeutic-Indications preferred terms could be composed using SNOMED CT concepts: none of these required more than 3 SNOMED CT concepts to compose. We describe the common composition patterns in the paper. About 30% of both Adverse-Event and Therapeutic-Indications Preferred Terms corresponded to single SNOMED CT concepts: the correspondence was detectable by human inspection but had been missed during the integration process, which had created duplicated concepts in UMLS. CONCLUSIONS: Identification of composite mapping patterns, and the types of errors that occur in the MedDRA content within UMLS, can focus larger-scale efforts on improving the quality of such mappings, which may assist in the creation of an adverse-events ontology.

Open notes: doctors and patients signing on.

Few patients read their doctors' notes, despite having the legal right to do so. As information technology makes medical records more accessible and society calls for greater transparency, patients' interest in reading their doctors' notes may increase. Inviting patients to review these notes could improve understanding of their health, foster productive communication, stimulate shared decision making, and ultimately lead to better outcomes. Yet, easy access to doctors' notes could have negative consequences, such as confusing or worrying patients and complicating rather than improving patient-doctor communication. To gain evidence about the feasibility, benefits, and harms of providing patients ready access to electronic doctors' notes, a team of physicians and nurses have embarked on a demonstration and evaluation of a project called OpenNotes. The authors describe the intervention and share what they learned from conversations with doctors and patients during the planning stages. The team anticipates that "open notes" will spread and suggests that over time, if drafted collaboratively and signed by both doctors and patients, they might evolve to become contracts for care.

More training needed in chronic care: a survey of US physicians.

PURPOSE: Although more than 125 million North Americans have one or more chronic conditions, medical training may not adequately prepare physicians to care for them. The authors evaluated physicians' perceptions of the adequacy of their chronic illness care training to and the effects of training on their attitudes toward care of persons with chronic conditions. METHOD: In November 2000 through June 2001, the authors surveyed by telephone a random sample of U.S. physicians who had > or =20 hours of patient contact per week. The interview instrument examined demographics, career satisfaction, practice characteristics, perceived adequacy of chronic illness care training in ten competencies (geriatric syndromes, chronic pain, nutrition, developmental milestones, end-of-life care, psychosocial issues, patient education, assessment of caregiver needs, coordination of services, and interdisciplinary teamwork), and effect of training on attitudes toward chronic illness care. RESULTS: Of 1,905 eligible physicians, 1,236 (65%) responded (270 family or general practitioners, 231 internists, 129 pediatricians, 335 nonsurgical specialists, and 271 surgeons). Most physicians reported their chronic disease training was less than adequate for all ten competencies. Family practitioners were more likely (p <.05) to report adequate training in seven competencies compared with internists, and in two to four competencies when compared with pediatricians, nonsurgical specialists, or surgeons. Most physicians reported that training had a positive effect on attitudes toward care of people with chronic conditions, including the ability to make a difference in their lives (74-84%). CONCLUSIONS: Physicians perceived their medical training for chronic illness care was inadequate. Medical schools and residencies may need to modify curricula to better prepare physicians to treat the growing number of people with chronic conditions.