Sharing electronic health record notes with patients is a practice being embraced nationwide by providers as a way to improve physician-patient communication and foster greater transparency.
However, EHR notes written by physicians are full of medical terminology and technical language, making them difficult for patients to understand. Complicating matters is the fact that the average American has a reading level between the seventh and eighth grade, while more than a third of the U.S. population have basic or below basic health literacy.
According to Hong Yu, professor in the Department of Quantitative Health Sciences at the University of Massachusetts Medical School’s College of Information and Computer Science, studies have shown that patients are confused by their EHR notes. However, an online tool now is helping patients who are struggling to understand clinical notes.
Developed by Yu and her students under a grant from the Department of Veterans Affairs, the Clinical NotesAid—a natural language processing system—is designed to help patients comprehend their EHR notes by linking medical jargon to corresponding lay terms, definitions and other related patient education materials.
All users have to do is copy and paste text from EHR notes into an on-screen box and press an on-screen button, which sets off a process to simplify complex medical terms by providing simpler definitions that are more understandable for lay people. NotesAid, which is publicly available, includes thousands of definitions of medical concepts.
“EHRs are full of medical jargon, abbreviations, and other domain-specific usages and expressions that do not work well for many patients,” says Yu, who is principal investigator of UMass Medical School’s Biomedical Informatics Natural Language Processing Group, which has been working on NotesAid under Investigator Initiated Research from the VA’s Health Services Research and Development Program.
“It’s not like you can Google this,” adds Yu, who also works at the Bedford VA Medical Center as a research health scientist. “All of this content we create ourselves.”
In 2013, the Veterans Health Administration began to make clinical notes in the VA’s legacy EHR system—the Veterans Health Information Systems and Technology Architecture (VistA)—available through the My HealtheVet patient portal.
Steven Dobscha, MD, director of the Center to Improve Veteran Involvement in Care at the VA Portland Health Care System, and his research team have been exploring the use of these so-called OpenNotes in mental healthcare via the MyHealtheVet portal which provides patients with online access to their clinical notes.
Dobscha contends that while patients might be confused and not understand some of the jargon in EHR notes, they’d rather have access to the information than not.
“Some of the notes can be pretty dry and technical,” he says. “One of the things we’re trying to do is prompt veterans to talk to their providers when they don’t understand something and ask questions.”
At the same time, Yu believes that NotesAid can be of assistance to physicians in translating complex EHR notes for patients as part of their medical discussions.
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