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Clinical Documentation in an Era of Increasing Transparency: The Impact of

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DOI: 10.12927/hcq.2017.25291

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 DIGITAL TECHNOLOGIES IN HEALTHCARE
Clinical Documentation in an Era of
Increasing Transparency:
The Impact of Electronic Portals on Care
Joanne Maxwell, Keith Adamson, Amir Karmali and Lee Verweel
Abstract
Electronic health records (EHRs) and consumer health
portals have implications for improving the quality and
cost-effectiveness of healthcare and make it much easier
for patients and families to access health information in
a timely and convenient manner. However, the accessi-
bility of information afforded by EHRs and health portals
changes the dynamic of control over health information in
very significant ways. Institutions and their clinicians have
typically been the caretakers of these documents; there-
fore, the introduction of portals represents a major cultural
shift in healthcare. The efforts of both clinicians and
patients are needed to effectively make this shift, as the
implementation of new technology is uniquely challenging
within a healthcare setting. An interactive workshop was
facilitated to understand clinicians’ perceived challenges
of this shift with a specific focus on the implications of
increased transparency and patients’ increased access
to health information.
Introduction
Clinical documentation is well regulated and is one of the most
basic professional responsibilities for all healthcare providers. The
Public Hospitals Act (1990) mandates that regulatory Colleges
publish standards for documentation practices, and that each
healthcare organization has policies which stipulate how clinicians
document care. In Canada, personal health records belong to the
patient, whereas the hospital or organization acts as the “custo-
dian” of the record. Nonetheless, very few users of the healthcare
system are empowered to read, or seek to read their clinical notes
(Delbanco et al. 2010). An emerging innovation in healthcare is
the electronic health record (EHR), which when accompanied
by a consumer portal, has the potential to change the dynamic
of control over the health information in very significant ways
(Bates and Bitton 2010; Betteridge 2014).
EHRs that are linked to consumer health portals are making
it much easier for patients and families to access health infor-
mation in a timely and convenient manner. Previous research
suggests that a shift to EHRs can create a collaborative environ-
ment, and that patients who have access to clinical notes could
improve their understanding of health, foster productive
communication and stimulate shared decision-making through
enhanced communication (Delbanco et al. 2010; Knaup et al.
2005; Kuhn et al. 2015). Typically, EHRs do not increase the
patients’ and families’ access to information on their own, but
EHRs can increase transparency between providers. Consumer
health portals, which are tethered to (or fed from) the EHR,
allow the patient to freely access their information.
EHRs are rapidly becoming more prevalent among clini-
cians in Canada. A recent survey of primary care physicians
found that the uptake of electronic medical records in Canada
Healthcare Quarterly Vol.20 No.3 2017 29
Clinical Documentation in an Era of Increasing Transparency: The Impact of Electronic Portals on Care Joanne Maxwell et al.

has increased from 56% to 73% between 2012 and 2015
(Osborn et al. 2015). The trend towards increased use of EHRs
and consumer portals is encouraging; however, research has
highlighted the unique challenges of implementing informa-
tion systems within a hospital setting, as compared to other
industries (Boonstra and Govers 2009). Hospitals have a varied
and highly skilled workforce, and can often have competing
priorities for care, which may complicate the uptake of EHRs
and consumer portals (Boonstra and Govers 2009). Thus,
consumer health portals present unique challenges to care and
a successful transition to electronic documentation requires
the cultivation of patient-centred behavior by clinicians and
hospital staff (Reti et al. 2010).
There is little known about the challenges that clini-
cians face in relation to increased transparency with clinical
documentation following the implementation of electronic
health portals where health records are readily available
to patients and their families. The literature that does exist
solely focuses on physician documentation and as a result, the
perceived challenges of other healthcare professionals with
regards to increased transparency of health records has not
been fully explored. This research aims to identify and under-
stand the distinct challenges that healthcare professionals may
encounter when implementing EHRs and consumer portals
into their workflow.
About the Workshop
Design
This project emerged from a workshop facilitated by authors
JM and KA to better understand the perceptions of different
members of the rehabilitation community in regards to increased
transparency of EHRs. The workshop consisted of two activi-
ties with the goal of accomplishing several learning objectives
(see Figure 1 for outline of workshop). Data from participants’
concerns related to increased transparency in clinical documen-
tation were documented based on Activity One and Activity
Two (Figure 1). A qualitative thematic analysis approach was
used to analyze the data using NVivo 11 software (QSR 2008).
Workshop objectives
The aim of this interactive workshop was to understand the
complexity of perceived challenges related to documenting in an
era of increased access to and transparency of health records by
healthcare consumers. This was accomplished by two activity-
based objectives. The first objective aimed to determine the
perceived obstacles and challenges of increased transparency
in clinical documentation as a result of introducing electronic
health portals. The second objective was facilitated to deter-
mine the perceived supports that could be put in place to assist
clinicians, patients and families and organizations through this
shift towards electronic access to health information.

FIGURE 1.
Flow chart of methods used for interactive workshop

Participants were introduced to the framework of the interactive workshop and were oriented
Lead-in
to the concept of electronic health records within the context of Canadian institutions

Participants were guided to start a “healthy debate” about the perceived obstacles and
Participants completed a self-reflection on the
Activity 1 challenges resulting from the increased transparency in clinical documentation that
concepts discussed in Activity 1
comes with new technology

As a transition to the second group activity, participants were informed that shifts to
Transition electronic health records can create challenges but also allow opportunities for sharing
of information and greater engagement for clinicians, organizations, clients and families

Participants individually completed a

Participants were asked what supports could be put in place for clinicians, organizations,
Activity 2 self-reflection, and the groups’ ideas were
clients and families to successfully move through this shift
captured on a flip-chart

30 Healthcare Quarterly Vol.20 No.3 2017

 Joanne Maxwell et al. Clinical Documentation in an Era of Increasing Transparency: The Impact of Electronic Portals on Care
Results
A total of 27 participants were included in the two workshop
activities. Table 1 summarizes the different roles that partici-
pants had within their institutions. Of the 27 participants, there
were a variety of backgrounds with the majority of participants
being clinicians (occupational therapists, social workers, etc.),
practice leaders and leadership staff (managers, directors). The
participants came from a variety of institutions across Ontario.
See Table 2 for the primary practice locations of participants.
The majority of participants were from pediatric hospitals and
treatment centres.
TABLE 1.
Summary of participant roles (N = 27)
Role
Family leader
Director/manager
Clinician/practice leader
Professor
Unknown
TABLE 2.
Summary of participants practice locations
Type of centre
Pediatric hospital/treatment centre
Hospital
University
Organization
Unknown
Four major themes emerged from the two activities in the
workshop, which were: (1) maintaining clinical standards for
EHRs; (2) shifting control of the clinical record; (3) equitable
access to electronic tools for patients and (4) supports for
implementing EHRs.
Maintaining clinical standards for EHRs
This theme highlights clinicians’ desire to establish standards
for electronic documentation to maintain the quality of the
health records and standard of care. This theme comprised
three sub themes: the inadvertent disclosure of patient infor-
mation; transparency of errors and feasibility of electronic
documentation.
The inadvertent disclosure of patient information empha-
sized participants’ concern for regulating the content of
the electronic health portals. For example, one participant
commented, “what if parents find out something that was
not disclosed to them? – i.e., diagnosis, history of birth event,
etc.” Many participants felt that the patient’s privacy needed
to be a top priority and perceived this as a potential barrier to
sharing information captured in EHRs through portals that
might be accessed by both the patient and caregivers. As one
participant noted, “documenting sensitive information that
[they] may not want to share with everyone if [the] portal [is]
available to patients and partners.” Despite the fact that all
Personal Health Information (PHI) is by its nature, sensitive,
navigating “sensitive information” emerged as a prevalent
topic among participants because many believed that there
should be some form of censorship or guidelines to frame
this information.
The transparency of errors was outlined by participants
who perceived an increase in transparency of health infor-
n mation also meant an increased opportunity for both clini-
1 cians and consumers to see errors in documentation. This
issue is twofold as increased access to clinical records may
11
also mean more opportunity for errors in documentation for
9 clinicians and patients (if they are privy to make changes to
1 the record). As one participant commented, “who manages
5 accuracy/consistency? More people accessing equals more
opportunity for error.” Many participants echoed this point
and questioned whether the guidance of their regulatory body
(i.e., their professional College) with respect to documenta-
tion practices was sufficient where consumer health portals
N were in place.
16 Nonetheless, there were issues presented related to
workflow that may not be moderated by regulatory bodies.
3
The feasibility of electronic documentation was emphasized
2 as an important factor in maintaining clinical standards for
3 EHRs. Many participants discussed the feasibility of prior-
3 itizing clinical narrative versus point form documentation
without compromising regulatory guidelines. One partici-
pant commented that the “change from writing by hand to
computer-based documentation continues to be somewhat
difficult [and the] process of analysis/clinical reasoning
seems to happen more effortlessly when written by hand.”
Participants perceived competing sources of guidance around
documentation, as one participant noted that “clinicians [may
be] documenting for ‘their protection’ on Colleges require-
ments versus documenting on patient facts/[prescription]/
impact,” the latter being a priority for their organization and
aligned with principles of patient-centred care.
Shifting control of the clinical record
This major theme highlights the challenges associated with
facilitating increased control of health information for patients
and their families. Sub themes of shifting control of the clinical
record, included: misinterpreting information; health literacy
of patients and families and changing expectations about the
ownership of clinical documentation.
Healthcare Quarterly Vol.20 No.3 2017 31
Clinical Documentation in an Era of Increasing Transparency: The Impact of Electronic Portals on Care Joanne Maxwell et al.
Misinterpreting information emerged as a concern for partici-
pants because many feared that as EHRs facilitated transpar-
ency of health information for patients, it would simultaneously
lead to a greater potential to misjudge their health informa-
tion. For example, one participant wrote that a “family/patient
could undergo stress when seeing results on portal (imaging,
bloodwork) before having opportunity to discuss with the
professional; often the patients will Google results and be
misinformed.” Allowing a patient to have increased autonomy
in viewing (and potentially interpreting) their health informa-
tion, poses challenges for clinicians who have typically had the
opportunity to consult with their patients to ensure that they
are providing comprehensive information, but also that the
information they are providing is understandable.
The health literacy of patients and their families was also
perceived as a pivotal challenge to increased transparency
through electronic portals. As one participant noted, “writing
for colleagues and families is [a] different level of description …
[and families] may not understand [the] info that other profes-
sions need.” Moreover, many participants voiced the difficulty
in conveying sensitive information that would often “require
additional support/interpretation.” Most participants believed
that when patients garnered more control and autonomy over
their record, there was a risk that they would access informa-
tion without clinician supervision and may not have the health
literacy to interpret their information independently. For these
reasons, participants seemed hesitant about patients and their
caregivers having increased control and ownership of their
clinical information.
Changing expectations about the ownership of clinical
documentation was an important consideration when clinicians
discussed shifting control of the clinical record. Clinicians
inferred that most of their clinical documentation is written
for themselves, or for other professionals using technical
language. Some participants eluded that this may be the case
because health records have conventionally been a “clinician’s
document.” However, with the introduction of EHRs and
portals, there is a need to write so that the document caters
to clinicians, patients and their families simultaneously. One
participant highlighted that competing priorities for care, make
it challenging to balance “objectivity – relevant clinical info;
parent inclusion/family centredness (collaborative language);
college regulation around reporting [and] time allotted to
complete notes.” Managing expectations surrounding the
control and recipients of clinical documents is essential when
introducing the EHR to patients, families and clinicians.
Equitable access to electronic tools for patients
This theme discusses technology-related barriers for EHRs,
more specifically, concerns related to patients and families
equitable access to electronic tools. Participants were concerned
32 Healthcare Quarterly Vol.20 No.3 2017
that shifting the culture of documentation may have implica-
tions for patients and their families who may not have access
to a computer or technology and moving to this system may
exclude people from care. As one participant stated “not all
families have access to computer or are computer literate.”
Ensuring that electronic systems function properly often
requires access to technological resources, which may be more
readily available in certain geographic regions, establishing a
potential gap in equitable access to care. In some cases, access
to a computer may act as a social determinant of health, and the
unequal access of this technology may affect a patient’s ability
to manage their care.
In addition to technological barriers, some participants
expressed that empowering patients and families through a
portal may be especially difficult as there may be cultural, as
well as language barriers in communication. This was outlined
by one participant:
“Foreign to other cultures/languages – more than 40%
of our families are newcomers to Canada. No access to
technology and also very different perspectives – Families
rely on translators, who often have their own biases/skills”
Encouraging fair and equitable access to EHRs and health
portals may pose a significant challenge, as access to technology
is often nested within larger social factors that may impact
a patient’s ability to seek care.
Supports for implementing EHRs
This major theme discusses the supports that participants
identified as being important to implement this shift in clinical
documentation. Three sub themes developed, which were:
training for clinicians, patients and families; incorporating infra-
structure for adoption of electronic health portals; and organiza-
tional collaboration.
Training for clinicians, patients and families highlights the
importance of training families and identified that the focus
of these trainings should be on managing the expectations of
patients and their families. Participants mentioned self-learning
tools such as “self-training (e.g., videos/Youtube) for families
on what to expect in a health record.” Other participants spoke
to the importance of training families on EHRs to help parents
“understand what [information] goes into a patient record.”
Despite the identified need for training of patients, there were
concerns regarding the added burden on clinicians to provide
this training. One participant suggested that organizations
strive to develop peer to peer support opportunities for training
patients and their families on how to use portals.
Moreover, participants identified several different modes
of training to help support healthcare organizations shift to
EHRs when discussing training for clinicians, patients and
 Joanne Maxwell et al. Clinical Documentation in an Era of Increasing Transparency: The Impact of Electronic Portals on Care
families. Participants spoke to the importance of being trained
in patient-centred or “family friendly language.” More specifi-
cally, in generating a transparent electronic health record, clini-
cians expressed their need to be trained on “what to include”
and how to “write notes using nonjudgmental language
(less subjective).” Furthermore, it was established that there
should be resources to educate clinicians on the system they
are working with directly and the “workload implications” of
EHRs. This would include privacy management, the strengths
and weaknesses of EHRs and “training in the value of patient
engagement in the process.”
Incorporating infrastructure for adoption of electronic health
portals underscores the importance of having infrastructures
for participation such as: guidelines, access to portals and
quality assurance checks. The types of guidelines suggested
were “standard templates for clinical staff” on how to use the
electronic health system, as well as, a type of “discussion check-
list” to use with families about what they need to know about
an EHR and the portal. Furthermore, participants suggested
that there be “quality assurance checks with feedback loops,”
and suggested that organizations “devote time to develop
standards of documentation” to provide feedback and support
to clinicians. Lastly, several participants believed that informed
consent around clinical documents content use was an impor-
tant organizational infrastructure that needed to be put in place
to smooth the transition.
Lastly, organizational collaboration was identified as an
important factor for implementing EHRs. Participants
highlighted that inter-organizational collaboration would
support the shift towards EHRs and consumer portals. One
participant noted that it would help to have “shared info
with other parties who have implemented a shared portal”
and “support from other centres with portals to assist with
troubleshooting.” Furthermore, participants mentioned that
regulatory colleges (e.g., College of Occupational Therapists
of Ontario) must also be supportive, as one participant noted
that support from these colleges may be crucial in “monitoring
for staff who need it/request it.”
In addition to organizational collaboration with external
stakeholders, intra-organizational collaboration was mentioned
by most participants as being essential in the support of
shifting to greater accessibility of clinical documentation. A
prevalent concept among participants was the idea of having
“champions” of EHRs. These champions are likely to be “early
adopters” and aim to “monitor those staff who request assis-
tance.” Furthermore, participants stated that dedicated time
to allow staff to “familiarize” themselves with adopting a new
system was essential in allowing for positive change. In addition
to this dedicated time, participants suggested that organiza-
tions provided “inservices/workshops for strength-based and
family-centred report writing.”
An overarching theme that emerged
from the data was a reluctance of clinicians
to share their authority and control over
health records …
Implications
Despite their positive potential with respect to improving
patient engagement and enhancing patient-provider commu-
nication, electronic health portals represent a significant
cultural shift in healthcare. Previous research has identi-
fied challenges in the adoption of EHRs and portals, such
as clinician resistance, concerns about liability, impacts on
patient-provider relationships and the alignment with juris-
dictional regulatory environments (Kahn et al. 2014; Naylor
et al. 2015).
The findings of this participatory workshop support a
need for consideration of the implications, both positive and
negative, of these changing technologies on clinical practice,
patient and family engagement and healthcare organizations.
Clinical practice implications
Participants in this interactive workshop had general concerns
about using electronic health portals, with distinct challenges
rooted in the increased access to, and transparency of, personal
health information, such as test results and clinical notes. An
overarching theme that emerged from the data was a reluctance
of clinicians to share their authority and control over health
records, which was perceived to be undermined by increased
transparency afforded by EHRs.
Clinicians of all disciplines need to understand the
patients’ rights with respect to accessing their health infor-
mation. The law in Canada (Government of Canada 2000;
Government of Ontario 2004) has been clear that the content
of the health record is the property of the individual, and this
access can only be denied in very specific circumstances. The
concerns expressed by clinicians suggest that education and
support are required in order for professionals to feel confi-
dent that their documentation is appropriate to be shared
with the patient and completed in a manner that supports
the patient in using this information to participate in care
and make informed healthcare decisions. This would apply to
practicing clinicians as well as to trainees, and it is important
that educational institutions begin to consider these shifts in
how documentation is accessed and used in designing and
providing training for emerging clinicians.
The adoption of electronic health portals by patients and
caregivers will be impacted by the degree to which clinicians
adopt the supporting technology. If the clinicians do not
provide meaningful information in their clinical notes, in
language that the patients can understand, then the usefulness
of a portal will be limited.
Healthcare Quarterly Vol.20 No.3 2017 33
Clinical Documentation in an Era of Increasing Transparency: The Impact of Electronic Portals on Care Joanne Maxwell et al.
As the custodians of the health records,
organizations have responsibility for ensuring
the privacy and security of the records, as
well as the quality of their content.
Implications for patient engagement and
empowerment
With increasing emphasis on providing coordinated, patient-
centred care (Hoskins 2016; Ontario Ministry of Health and
Long-Term Care 2010), tools, such as consumer portals, that
support sharing of information are likely to continue to prolif-
erate. There is emerging evidence that the sharing of clinical
notes with patients can create a more collaborative environ-
ment, may lead to improved understanding of their health and
promote shared decision-making through enhanced commu-
nication (Delbanco et al. 2010; Knaup et al. 2005; Kuhn et al.
2015). While much more research is needed to determine the
impacts of portals on engagement, King et al. (2016) suggests
that communication and engagement may be positively
impacted through the sharing of information through portals.
To optimize such an impact, it will be critical that the informa-
tion being shared is understandable to the patient, meaningful
to the patient and actionable. Reti et al. (2010) noted that
a dedication to the patient perspective is required. To best
address this challenge, healthcare consumers must be engaged
to inform the likely changes in documentation. In parallel to
educating clinicians on how best to document care to ensure
patient understanding, efforts to improve health literacy levels
may also be helpful in optimizing the impact of portals on
healthcare outcomes as low health literacy has been linked with
poor health outcomes for patients (Baker et al. 1997; Scott
et al. 2002; Weiss et al. 1992).
Implications for healthcare organizations and
regulatory bodies
With the use EHRs rapidly increasing within hospitals in
Canada, balancing the needs of healthcare providers with
respect to their clinical documentation with the health literacy
of patients and families will be a necessary consideration for
healthcare organizations. As the custodians of the health
records, organizations have responsibility for ensuring the
privacy and security of the records, as well as the quality of
their content. These responsibilities are further heightened
when organizations implement technologies that increase the
accessibility of the information contained in these records.
From the perspective of staff satisfaction, previous research has
identified that healthcare workers’ use of EHRs (even without
a portal) has been associated with job dissatisfaction, burnout
and increased workload (Friedberg et al. 2013).
Many participants identified the perceived increase in time
and effort required to manage the expectations of patients
34 Healthcare Quarterly Vol.20 No.3 2017
and families and ensure that notes were comprehensible. This
potential increase in workload must be considered as having
implications for clinicians and the healthcare system in general.
Organizations can learn from previous studies that have identi-
fied factors that can support clinician adoption and comfort
with new technologies including exposure to the system,
support from clinical leaders and paid training sessions (Ash
and Bates 2005; Poissant et al. 2005).
In addition to the support at an organizational level, the
support from regulatory colleges may mitigate potential issues
with increased transparency in documentation. Professional
regulatory bodies can play a significant role in supporting
clinicians through the promotion of appropriate utilization
of technologies by clinicians and in ensuring the alignment
of regulations with changing practice conditions (Stern et
al. 2014; Zelmer and Hagens 2014). Although most clinical
documentation guidelines comply with regulatory require-
ments, they do not necessarily balance patient expectations
for greater transparency and engagement in decisions (Naylor
et al. 2015). The challenging aspect of both organizational
and regulatory guidelines is that documenting clinical notes
within an electronic portal requires a conscious effort to abide
by guidelines while simultaneously writing for patients.
Limitations
Even though the results from this workshop are insightful, they
are limited by the fact that participants were given cues as to
what the issues they might face in using EHRs to share clinical
documentation through electronic portals. While EHRs may
pose challenges to patient interactions, electronic documenta-
tion has been found to create time savings for clinicians in other
activities, such as accessing a patient’s chart (Bates et al. 1994)
or maintaining patient report forms (Tierney et al. 1993).
Participants in our interactive workshop were not specifically
asked to draw upon their perceived benefits of using EHRs or
sharing documentation with patients and caregivers through
portals. Furthermore, the difficulties that participants identi-
fied may be because of the perceived challenges associated with
transitioning to EHRs, rather than deep rooted flaws of the
technology itself.
Conclusion
We found that the majority of our participants had appre-
hensions about increases in transparency afforded by portals
because of the potential implications for their workflow, their
ability to maintain their current standard of care and a perceived
need for guidance and governance of health information. Future
research is needed to influence and study the impact of the use
of electronic portals on clinical documentation practices and
to understand the implications of increased access to clinical
records on patient care and clinical outcomes. 
 Joanne Maxwell et al. Clinical Documentation in an Era of Increasing Transparency: The Impact of Electronic Portals on Care
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About the Authors
Joanne Maxwell, MSc, OT Reg. (Ont.), CHE, is interim senior
director, Collaborative Practice at Holland Bloorview Kids
Rehabilitation Hospital, and adjunct lecturer, Department of
Occupational Science and Occupational Therapy at the University
of Toronto.
Keith Adamson, PhD, is an assistant professor at the Factor-
Inwentash Faculty of Social Work at the University of Toronto.
He specializes in professional practice.
Amir Karmali is a family-centred care specialist at Holland
Bloorview, where he leads aspects of client and family-centred
care initiatives.
Lee Verweel, MSc, is a research assistant in the Bloorview
Research Institute.
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