An Assessment of Open Access Audio of the Clinical Encounter on Veterans and their Care

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Background: The medical encounter can be overwhelming in term of the amount of information discussed, its technical nature, and the anxiety it can generate. Easy access to a secure audio recording from any internet enabled device is an available low cost technology that allows patients to “revisit the visit” either alone or sharing with caretakers and family. It has been introduced and tested outside the VA with evidence that it increases patient recall and understanding and may even improve physician performance. Little is known, however, about whether and to what extent these effects lead to better outcomes, such as improved treatment plan adherence and chronic disease self-management. Significance/Impact: This study will assess a new resource for enhancing Veterans capacity to understand their care plan, and share information from their visit with caregivers. The study design is intended to yield information to guide decision makers about the value of bringing “open access audio” (OAA) to VHA. Innovation: The Open Chart movement, in which patients can freely access their written medical information was a major innovation first introduced through the patient portal in 2010, and is rapidly disseminating-- including within VHA. OAA extends the same principles of full transparency and easy access to medical information and, if successful, could also be incorporated into the patient portal. The VHA Office of Connected Care, which manages MyHealtheVet has indicated interest in this project because of its potential to transform the next generation portal. Specific Aims: This study will access, using a randomized controlled trial design, whether the known benefits of OAA (better patient recall and understanding) lead to several desired service utilization and health care outcomes. It will also measure the effect of OAA on provider behaviors that may mediate those outcomes. Throughout, data will be collected on participant and other stakeholder perceptions of the program that, based on prior research on audio- recording in the clinical setting, reflect a readiness to adopt the new technology. Aim 1: Assess the impact of an open access audio program on two behaviors (patient activation, treatment plan adherence), and two chronic condition measures (glycosylated hemoglobin, blood pressure). Secondary analysis will descriptively measure effect size on ED visits and hospital admissions. Aim 2: Assess the impact of open access audio on provider communication and on their attention to patient contextual factors (i.e. individual Veterans needs and circumstances relevant to planning effective care). Aim 3: Assess patient, provider, and leadership perceptions of the extent to which the program is safe, not burdensome, and worthwhile at both the start and at two years into the program. Methodology: The setting will be primary care and diabetes clinics, at two facilities for generalizability. To achieve aims 1 and 2, we propose a randomized controlled three arm design: (1) the encounter is recorded, with provider and patient aware, and uploaded to a server the Veteran, provider, and research team can access post visit; (2) the encounter is recorded, with both parties aware, and uploaded to a server only the research team can access; and (3) the encounter is recorded, with only the patient aware, and uploaded to a server only the research team can access. Resource utilization and disease measures indicated in aims 1 and 2 will be collected in all arms. Comparisons of Arms “1” and “2” enable assessing the impact of the availability of audio on patients (for aim 1). Comparisons of Arm “2” with “3” enables isolating the effect of providers knowing they are being recorded (for aim 2). Data for aim 3 will come from survey tools, focus groups and semi-structured leadership interviews to elicit perceptions of project safety, burden, and value. Next Steps/Implementation: We will work with the Office of Connected Health to identify opportunities, based on the findings for incorporating Open Audio Access into the next generation patient portal.