Patient Access to Electronic Health Records During Hospitalization

In 2001, the Institute of Medicine¹ recommended improving patient engagement by providing continuous care, allowing patients to be the source of control and fostering transparency with patients and families. Electronic health records (EHRs) facilitate these objectives via the use of patient portals.² Giving outpatients direct access to their health information helps clinicians find errors and improves patient satisfaction, although the implications of this type of access have not been well studied in the inpatient setting.^3-5 This hospital-based study evaluates the experiences of patients, clinicians (including physicians and advanced practice providers), and nurses with immediate (real-time) release of test results and other EHR information through a patient portal.

This prospective cohort study was performed on a medical unit of the University of Colorado Hospital, Aurora, a 412-bed academic tertiary care hospital, from October 1, 2012, through March 31, 2013. Approval was obtained from the Colorado Multiple Institutional Review Board and the University of Colorado Hospital Research Review Committee. Participants provided oral informed consent, and all data were deidentified. Participants included hospital clinicians, nurses, and patients. Patient participants were enrolled by convenience sampling and used a study-provided electronic tablet to access parts of their EHR, including the medication schedule and test results (intervention). Patients, clinicians, and nurses completed surveys before and after the intervention. The survey evaluated the domains of caregiver workload, patient confusion and worry, patient empowerment, errors detected, and discharge planning. We performed the McNemar test to analyze binary data between paired responses on surveys for all 3 groups.

Participants completing the preintervention and postintervention surveys included all 50 patients (response rate, 100%), 28 of 30 clinicians (response rate, 93%), and 14 of 16 nurses (response rate, 88%). Demographics and baseline opinions about technology are shown in Table 1. Mean patient portal use was 15.6 (SD, 16.2; median, 11.2; range, 0.3-86.8) clicks per day, and time logged on ranged from 2 to 1331 minutes. We did not assess the use of the tablet for other purposes or by other users. Table 2 shows the preintervention and postintervention survey results. Thirty-three of 42 clinicians and nurses (79%) were concerned that giving patients immediate access to their test results would increase their workload, but this sentiment decreased in both groups after the intervention. Concerns that seeing test results would cause patient worry were high among clinicians and nurses (24 of 28 [86%] and 13 of 14 [93%], respectively) and greater than among patients before the intervention, but these concerns decreased in all groups. Most patients endorsed empowerment items, including control, understanding, reassurance, and following recommendations both before and after the intervention.

Clinicians (25 of 26 [96%]) and nurses (13 of 14 [93%]) were more optimistic than patients (22 of 50 [44%]) that patient access to their medication lists would help them find errors, and this optimism decreased significantly across all groups after the intervention (patients, 3 of 50 [−38%; P < .001]; clinicians, 17 of 26 [−31%; P = .008]; and nurses, 7 of 14 [−43%; P = .03]). Before the intervention, 33 of 49 patients (67%) indicated that they would better understand when they would be discharged; after the intervention, the number of patients endorsing this item fell significantly (to 12 of 49 [−43%; P < .001]).

The suspected risks of giving inpatients direct access to their EHR did not bear out, with no increase in workload reported by the nurses or the clinicians and no increase in confusion or worry reported by the patients. Consistent with outpatient studies, patients answered more positively to empowerment questions after being given EHR access. Despite supporting patient empowerment, the promise of patients finding errors in their medications or knowing when they were being discharged never materialized. This study is, to our knowledge, the first published evaluation of the experience of a large sample of inpatients and their frontline health care practitioners with real-time inpatient EHR access, although it involved patients and practitioners on a single hospital unit. Federal programs recommend that patients be able to access results from their hospitalization within 36 hours of discharge.⁶ Based on our results, we believe that this requirement still misses an opportunity for patient engagement through better transparency, and future policies should consider real-time EHR access for inpatients.

Corresponding Author: Jonathan Michael Pell, MD, Division of General Internal Medicine, Department of Internal Medicine, University of Colorado School of Medicine, 12401 E 17th Ave, Mail Stop F782, Aurora, CO 80045 (jonathan.pell@ucdenver.edu).

Published Online: March 9, 2015. doi:10.1001/jamainternmed.2015.121.

Author Contributions: Dr Pell had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Pell, Limon, Lin.

Acquisition, analysis, or interpretation of data: Pell, Mancuso, Oman, Lin.

Drafting of the manuscript: Pell, Mancuso, Oman, Lin.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Pell, Mancuso, Oman, Lin.

Obtained funding: Pell.

Administrative, technical, or material support: Pell, Mancuso, Lin.

Study supervision: Pell, Lin.

Conflict of Interest Disclosures: None reported.

Funding/Support: This study was supported by the University of Colorado Hospital Clinical Effectiveness and Patient Safety Small Grants Program.

Role of the Funder/Sponsor: The funding source had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Additional Contributions: Esther Langmack, MD, CCMEP, Division of Pulmonary Sciences and Critical Care Medicine, Department of Internal Medicine, University of Colorado School of Medicine, provided editorial assistance in preparing the manuscript. Carl Miller, MA, Patient and Family Centered Care, University of Colorado Hospital, informed the project from a patient perspective, and Alice Pekarek RN, BSN, Clinical Informatics, University of Colorado Health, provided the nursing informatics perspective. None of these contributors received compensation for their roles.