Getting it Write: Primary care staff perspectives on writing consultation notes in a new era of patient online access

Problem

Electronic Health Records (EHRs) have traditionally prioritised the needs of healthcare professionals (HCPs), functioning as a professional tool to facilitate clinical communication and decision-making.In November 2023, NHS England introduced a policy enabling most patients in England to access new free-text consultation entries in their primary care EHR, via the NHS App or other online services. Research indicates that HCPs are apprehensive about patients reading their notes and are concerned that this may lead to increased workloads and compromise the clinical value of the EHR.Our study aimed to investigate how HCPs can be better supported in meeting patients' needs when composing entries in a patient's EHR, while ensuring that these records effectively contribute to providing high-quality clinical care.

Approach

We conducted online interviews and focus group discussions with 13 healthcare professionals working in a variety of primary care roles and settings. We asked staff how they currently used consultation notes within their professional roles and to identify the key benefits and challenges of providing patients with online access to their notes. Finally, we asked staff to reflect on the findings from the first phase of this study and to comment on a range of potential solutions to addressing the needs of multiple users.

Findings

We identified four key themes in the data. 1. Consultation notes were not designed for patient audiences2. Consultation notes help health professionals to maintain effective clinical care3. Patient online access impacts on our workload and how we practice 4. ‘Getting it Write’ for everyone is challengingOur discussions highlighted that although staff acknowledge that patients may benefit from access to their notes, they anticipate that many patients may struggle to understand them. Staff described diverse documentation styles and noted the critical role of consultation notes in clinical care and medico-legal compliance. Concerns were raised that tailoring documentation for patients could compromise patient safety and EHR value. Most staff felt they would benefit from further training and guidance in how to effectively address patients’ needs and expressed a preference for technical adaptations that maximised patient understanding with minimal impact on workloads.

Consequences

Staff acknowledge that patients may have difficulties understanding their health records but have concerns that adapting notes for patient audiences will diminish the clinical value of their notes and increase workloads and cognitive burdens. Balancing clinical integrity and patients' needs are crucial to the successful implementation of policy and the effective mitigation of unintended consequences. This study underlines the need to support healthcare professionals with navigating this challenge safely and effectively. Further research is urgently needed to explore the development of technological solutions that support patient understanding of consultation notes without increasing cognitive burden and clinical workloads.