Background: Confidentiality within adolescent medicine is imperative in establishing a trusting patient-physician relationship. In April 2021, the 21st Century Cures Act granted patients’ guardians immediate access to select patient electronic medical records. Whereas Pediatric Hospital Medicine (PHM) history and physical (H&P) notes are visible to guardians, adolescent sensitive notes (ASN) remain confidential. At our institution, we strongly recommend two social history domains, sexual history and substance use, are documented in the ASN and not in the H&P. Our prior research demonstrated that 84% of encounters with sexual history documentation had it documented in the H&P, and altered mental status was a common reason this history was not in the H&P. Our aim was to decrease sensitive information in H&P notes and increase utilization of ASN.
Methods: We queried our electronic medical record for PHM encounters in patients age 13 through 17 from 8/1/2020 to 5/31/2021. Patients with documented developmental delay or altered mental status on admission were excluded. We performed two quality improvement (QI) interventions 1) disappearing help text added to our PHM H&P template prompting proper documentation of the two social history domains in the ASN on 10/17/20 and 2) editing the disappearing help text to encourage copy/paste of the two social history domains into the ASN on 2/8/21. Education regarding the 21st Century Cures Act and the utilization of ASN was provided to residents and advanced practice providers. The primary outcome measure was documentation of the two social history domains in H&P notes. The process measure was presence of adolescent sensitive notes. The balancing measure was documentation of other unapproved social history domains in the ASN. For February through May 2021 encounters, associations between patient and encounter characteristics and presence of ASN were assessed using Chi-squared statistics in order to inform future interventions.
Results: Out of 545 encounters, 450 met inclusion criteria. There was decreased documentation of sexual history and substance use within H&P notes from 58.4% and 50.4% to 8.4% and 11.4%, respectively (Figure 1). Both measures showed special cause variation. There was increased utilization of ASN after implementation of disappearing help text from 22.8% to 72.3% at the end of the study, showing special case variation (Figure 2A). Other unapproved domains in the ASN decreased over time (Figure 2B). For February through May 2021 encounters, utilization of ASN was not associated with sex (p=0.173), insurance (p=0.087), race (p=0.474), ethnicity (p=0.807), and advanced practice provider (APP) compared to resident author of H&P (p=0.439). ASN was present in 64.1% (50/78) of patients aged 13-14 years old compared to 77.4% (96/124) of patients aged 15-17 years old (p=0.04). ASN was present in 96.0% (48/50) of patients who endorsed having had sex and 86.4% (95/110) who denied ever having had sex (p=0.067).
Conclusions: The QI intervention of disappearing help text in PHM H&Ps was associated with increasing utilization of ASN and decreasing documentation of sexual history and substance use within H&P notes. Balancing measures showed improvement. This simple intervention helps maintain confidentiality in the setting of the 21st Century Cures Act. Further interventions may include utilization of disappearing help text in other specialties.