OBJECTIVES

Confidentiality is imperative when caring for adolescents, yet the 21st Century Cures Act ensures guardian access to some of their child’s documentation. Pediatric Hospital Medicine (PHM) history and physical (H&P) notes are visible to guardians, whereas adolescent sensitive notes (ASN) are not. Our aim was to decrease sexual history and substance use (SHSU) documentation in H&P notes.

METHODS

This quality improvement study included adolescents ages 13 to 17 from August 1, 2020 to May 31, 2021. Interventions included disappearing help text added to PHM H&P template prompting placement of positive SHSU in the ASN, editing of disappearing help text to encourage copy and paste of all SHSU into ASN, and communication to providers. The primary outcome measure was documentation of SHSU in H&P notes. The process measure was presence of ASNs. The balancing measures were documentation of unapproved social history domains in the ASN and encounters with no SHSU documentation. Statistical process control was used for analysis.

RESULTS

Four hundred fifty patients were included in this analysis. There was decreased documentation of SHSU within H&P notes from means of 58.4% and 50.4% to 8.4% and 11.4%, respectively. There was increased utilization of ASN from 22.8% to 72.3%. Special cause variation occurred. Other unapproved domains in the ASN decreased. Encounters with no SHSU were unchanged.

CONCLUSIONS

The quality improvement intervention of disappearing help text in PHM H&Ps was associated with decreased documentation of SHSU within H&P notes and increased utilization of ASN. This simple intervention helps maintain confidentiality. Further interventions may include utilization of disappearing help text in other specialties.

Confidentiality when caring for adolescent patients is imperative in establishing a trusting patient-physician relationship. Literature confirms that some adolescents will only discuss their concerns with a health care professional if done so in the absence of guardian involvement, and ethical and professional frameworks support confidentiality within adolescent medicine when necessary.15 

In April 2021, the 21st Century Cures Act granted patients’ guardians immediate access to select patient electronic health records (EHR), creating several challenges for adolescents.6,7  Interpretation of adolescent health privacy law involves ambiguity and varies based on state and institutional practices.8  In April 2021, our institution provided Epic MyChart access for guardians to view the EHR easily. Therefore, the use of confidential note types has become important.9  Whereas Pediatric Hospital Medicine (PHM) history and physical (H&P) notes are visible to guardians, adolescent sensitive notes (ASN) remain confidential in MyChart and are not released unless a guardian specifically requests a paper medical record.

At our institution, only gender identity, sexual history, and substance use history are allowed in the ASN. Other social history domains are not documented in the ASN so as not to be interpreted as information blocking. ASN are separate from the H&P, which requires 2 separate notes per admission. ASN were available before our study and their use was encouraged by hospital leadership; however, most providers did not use ASN because it was cumbersome to document in multiple places and before the Cures Act, guardians did not have access to notes in MyChart. Our prior research demonstrated, of encounters with sexual history documentation, 84% included this information in the H&P.10 

Templates within the EHR can lead to more complete documentation and improvement of care plans.1113  With the use of disappearing help text within our H&P templates, we aimed to decrease this sensitive information in our H&Ps. The primary aim of this study was to decrease sexual history and substance use (SHSU) information in H&P notes to less than 20% in 10 months.

This quality improvement (QI) study was conducted in a 300-bed Midwestern tertiary academic children’s hospital. The PHM division consists of 33 pediatric hospitalists, 10 advanced practice providers (APP), 4 PHM fellows, and ∼100 pediatric residents who care for patients on the PHM service. The EHR is Epic (Verona, WI). A team of providers reviewed current H&P workflows to generate a key driver diagram (Fig 1).

Intervention 1: Disappearing Help Text Added to PHM H&P Template

Disappearing help text is text within the note template that disappears when the provider signs the note. All providers use H&P templates as a guide for history taking, making it an ideal location for interventions. To keep all prompts in 1 place, we only used the disappearing help text in the H&P. The standard H&P template includes prompts for SHSU to ensure it is completed. A disappearing help text, which stated, “Document any endorsement of sexual or drug activity (and any social history the teenager would prefer to keep private) in an Adolescent Sensitive note” was added to PHM H&P templates, prompting proper documentation of any positive SHSU in the ASN on October 17, 2020.

Intervention 2: Editing the Disappearing Help Text

Given we found many encounters in which only positive SHSU were documented in the ASN, we edited the disappearing help text within PHM H&P templates to be more direct: “CUT/PASTE the alcohol/drug and sexual history into an Adolescent Sensitive note for every patient (even if denies behaviors),” which encouraged copy and paste of any SHSU into the ASN on February 8, 2021, even if the patient denied sexual activity or substance use.

Intervention 3: Communication

Several meetings and e-mail communications occurred throughout the Cures Act transition in our hospital to encourage the use of the ASN.

Studying the Interventions

PHM encounters in patients ages 13 to 17 from August 1, 2020 to May 31, 2021 were included. Patients with documented developmental delay or altered mental status on admission were excluded. Chart review was performed on PHM encounters to determine whether the 2 recommended social history domains, SHSU, were documented in the ASN and not in the H&P. Additional data collected via chart review included: sex, insurance, race, ethnicity, and APP compared with resident author of H&P. REDCap was used for secure database management.

The primary outcome measure was documentation of the 2 social history domains, SHSU, in H&P notes. The process measure was presence of ASN. The balancing measure was the percentage of encounters that did not include SHSU in the H&P or ASN and documentation of other unapproved social history domains in the ASN. The unapproved domains are the additional questions in the social history exam excluding SHSU, which are home environment, education, activity, safety, and suicide or self-harm. Our institutional policy was that suicide and self-harm was not to remain confidential, as this posed a safety concern.

For February through May 2021 encounters, associations between patient and encounter characteristics and presence of ASN were assessed using χ2 statistics to inform future interventions. Control charts were used to assess for special cause variation.

This project was determined not to be human subjects research by the Institutional Review Board.

Out of 545 encounters in August 2020 through May 2021, 450 met inclusion criteria. Intervention months (February through May 2021) included 202 patients. Demographics for patients throughout the entire study period are shown in Supplemental Table 1. The following percentages presented are means.

There was decreased documentation of SHSU within H&P notes. Sexual history documentation decreased from 58.4% to 8.4%. Substance use documentation decreased from 50.4% to 11.4% (Fig 2). Both showed special cause variation.14 

There was increased utilization of ASN after implementation of disappearing help text from 22.8% to 72.3% at the end of the study, which showed special case variation (Fig 3).14 

Other unapproved domains in the ASN decreased from 90.7% to 54.9% at the end of the study (Fig 4). Percent of encounters that did not have substance abuse or sexual history documented in either the H&P or the ASN remained the same throughout the study at 18.4% and 20.7%, respectively.

After the final intervention, ASN was present in 64.1% (50 of 78) of patients 13 to 14 years old compared with 77.4% (96 of 124) of patients 15 to 17 years old (P = .04). ASN was present in 96.0% (48 of 50) of patients who endorsed having had sex and 86.4% (95 of 110) who denied ever having had sex (P = .067). After the final intervention, utilization of ASN was not associated with sex (P = .173), insurance (P = .087), race (P = .474), ethnicity (P = .807), and APP compared with resident author of H&P (P = .439).

We surpassed our primary aim and decreased SHSU documentation in our H&Ps. There was also increased utilization of ASN, our process measure, after implementation of disappearing help text. The success of the study is likely related to all interventions; adding disappearing help text to PHM H&P templates prompting proper documentation of the 2 social history domains, editing the disappearing help text to encourage copy and paste, and communication with providers.

Our results align with our theory of improvement that EHR templates can assist in proper documentation. The initial disappearing text was associated with special cause variation for sexual history documentation but not for substance use, whereas the second EHR intervention was associated with special cause variation for both measures. This may be because of multiple factors, such as a stronger provider motivation to keep sexual history private, more direct wording of the second disappearing help text, increased communication during this time frame, or general awareness and increasing proximity to the enactment of the Cures Act. Improved and stable balancing measures suggest providers are reading the disappearing help text and not documenting unapproved domains in the ASN and not omitting SHSU history.

Analysis of patient factor relationships demonstrated a significant increase in utilization of ASN in patients aged 15 to 17 years compared with those aged 13 to 14 years. This may be because of the expectation that SHSU is more common in older adolescents. Our analysis also demonstrated increased utilization of ASN in patients who endorsed having sex compared with those who denied ever having sex. Although not statistically significant, this result may be because of the provider wanting to ensure confidentiality in those patients who endorsed having sex. The sample size of this population was small, therefore the power to see a significant difference may be lacking.

Prior literature demonstrates the importance of confidentiality to ensure open communication between adolescents and health care providers.14  This has become especially important as implementation of open notes within the 21st Century Cures Act has raised both ethical and legal concerns.6  One prior study explored complex cases in the setting of open notes and concluded that targeted education and electronic health record modifications are necessary to maintain confidentiality and avoid inadvertent disclosures.15  Another study demonstrated that utilization of confidential notes in ambulatory care was shown to support the protection of confidential information in the setting of pediatric open notes implementation.9 

It is also well-documented that EHR templates can be beneficial in ensuring complete documentation.11  A study at our institution was successful in customizing EHR templates to align with clinical practice guidelines to decrease antibiotic exposure in infant sepsis evaluation.13  Our analysis aligns with prior literature, as the disappearing help text within PHM H&P templates resulted in significant improvement of proper documentation of SHSU. The outcome of our analysis supports the integrity of the adolescent and health care provider relationship by maintaining confidentiality.

Our study was conducted at a single academic children’s hospital and focused only on PHM admissions. Other institutions would have to develop disappearing help text with their EHR analysts, which may be a limitation. Furthermore, needing to document 2 separate notes within 1 encounter may place additional documentation burden on clinicians, which may hinder the use of ASN.

The QI intervention of disappearing help text in PHM H&Ps was associated with increasing utilization of ASN and decreasing documentation of SHSU within H&P notes. Balancing measures showed improvement. This simple intervention helps maintain confidentiality in the setting of the Cures Act. Further interventions may include utilization of disappearing help text in other specialties and to prompt appropriate documentation in other scenarios.

FUNDING: No external funding.

CONFLICT OF INTEREST DISCLOSURES: The authors have indicated they have no potential conflicts of interest to disclose.

Dr Skrzypcak is the corresponding author and resident principal investigator; she drafted the initial version of the manuscript, interpreted the data, and revised the manuscript; Drs McFadden and Bauer developed the clinical decision support tools and project design, interpreted the data, and assisted in manuscript revisions; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

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Supplementary data