PHM Fellow Valley Children's Healthcare Fresno, California, United States
Background: The 21st Century Cures Act has expanded and eased the accessibility that patients and caregivers have to their medical records including medical documentation. As this information becomes more readily available, patients/caregivers are able to review their own and their child’s medical documentation in almost real time. Previous studies have demonstrated the effect that language in documentation can have on medical providers and their perceptions/opinions of the patients/families they are caring for. For instance, in Goddu et. al they compared physician responses when reading similar hypothetical patient notes that used stigmatizing vs neutral language and found an overall more negative attitude towards the patient with the stigmatizing language. However, to date most of the studies on the effect of the language used in documentation have been from the provider’s perspective and perceptions. Relatively few studies have been conducted on how patients/families are utilizing their online medical record and what opinions/perceptions they have on the information and documentation they now have access to. Objective: The aim of this study is to conduct semi-structured interviews to assess how families are utilizing their child’s online medical record and the opinions/perceptions they have on the language used in the documentation therein. Design/Methods: Families/Caregivers participating in this study were selected via convenience sampling from the general pediatric inpatient service. We conducted semi-structured interviews with families of patients admitted to Valley Children’s Hospital in Madera, CA who were primarily English or Spanish speakers and who had accessed and utilized their child’s online medical record. Interviews were audio recorded and transcribed. The data was analyzed by multiple researchers using systematic thematic analysis. Codes will be iteratively reviewed and modified by the research team. The team will then use adjudication to come to a consensus on final codes.
