Summary of major findings

This is the largest survey conducted into the experiences and opinions of GPs in England about patient ORA. Most respondents were aware that the GP contract in England required surgeries to offer patients full online access on request. By March 2022, a quarter of GPs in our study reported enabling ORA for the majority of their patients. Only a third of surveyed GPs believed offering patients access to their online records was a good idea.

The overwhelming majority of surveyed GPs believed patients would worry more after accessing their records, with a similar proportion (85%) believing most would find their records more confusing than helpful. However, our findings also revealed that GPs believed there were benefits to patients from access. The majority of GPs believed access would improve patient recall about their care plan, enhance patients’ sense of control over their care and help patients identify significant errors in their records. In addition, approximately half of those surveyed believed access would help patients better understand their health and medical conditions, better adhere to their medications and be better prepared for consultations.

Despite the experienced and anticipated benefits to patients, GPs are worried about the work burdens of ORA on their practices. More than 9 in 10 surveyed GPs believed patient online access would lead to increased patient contact. Most GPs also believed consultations would/already take longer as a result, with more time spent answering questions outside of consultations. Perhaps as a result, 7 in 10 GPs did not agree access would increase care efficiency. The majority were also sceptical that patient satisfaction or safety would improve as a result of patient access. Finally, more than 6 in 10 GPs believed the risk of patients taking legal action against them would increase after ORA.

Comparison with other studies

Our survey supports recent qualitative research in England, which shows clinicians express partial ambivalence and scepticism about the impact of ORA on patients.25 26 Strikingly similar views have also been reported cross-culturally in countries where access is now more advanced. For example, multiple surveys in the USA and Sweden reveal that a majority of clinicians, especially those with limited experience of the practice, expressed hesitancy or resistance to the practice.13 27–29 Relatedly, most respondents reported awareness that the GP contract committed practices to offer patients full online access by request, yet only a minority reported offering most patients ORA. Professional reluctance to raise awareness about access is also found in other countries. For example, in a survey of doctors in the USA, even after opening visit note summaries to patients, 78% (n=620) admitted that they did not encourage patients to read their documentation.30 Indeed, in a recent qualitative study among patients in England, participants reported that online access should be better promoted.17

Our results also echo studies in other countries, which show doctors anticipate patients will feel more in control of their care and better remember their care plan after accessing their records.11 12 Equally, our findings also resonate with research conducted in Sweden and the USA demonstrating most clinicians doubt patients’ ability to handle what they read, anticipating patients will worry more and find their records more confusing than helpful.11–13 Clinicians’ doubts tend to dissipate over time and with experience with ORA.21 Notably, to date, studies consistently show the majority of patients who access their records, including those with chronic illnesses, describe multiple benefits, with few reporting feeling ‘very confused’ or ‘more worried’ by what they read.18 19 31–35

Again, like previously published surveys in other countries, most of the English GPs we surveyed worried about access encroaching on their workload.25 26 This theme is also predominant in survey findings in other countries. For example, in a recent US study of 116 primary care physicians, 69% anticipated spending significantly more time addressing patients’ questions outside of consultations prior to patient access to open notes (ie, free text entries about patient visits); however, after implementation, only 8% reported having to spend more time addressing patients’ questions outside consultation hours.21 Using objective measures of messaging—such as email volume—in 2012, a US survey by Delbanco et al found no significant changes in the 12 months before compared with the 12 months after open notes were implemented.11 In a more recent US survey led by DesRoches, among clinician respondents who had offered online patient access to open notes for at least 1 year, 86% (n=1112) reported that in the previous 12 months, patients contacted them less than monthly or never with questions related to their documentation.30 However, other studies show that when it comes to accessing the full electronic health record, there is potential for increased patient contact. In a systematic review of primary care settings, Mould et al found the provision of ORA resulted in a moderate increase in email traffic but no change in telephone contact, with variable changes to face-to-face contact.36 Another recent study in the USA found that, after the implementation of ORA, the number of messages sent by patients within the 6 hours after patients reviewed the results doubled.37

More than half of surveyed GPs in our study believed patient access would negatively affect patient safety, a finding that was particularly noteworthy considering 60% (240/400) of GPs agreed that patients would find significant errors in their notes. Our respondents’ views contrast with multiple studies that suggest open notes might function as a safety mechanism,38–40 a conclusion that is supported by systematic reviews and meta-analyses.41 42 Studies show that with more eyes on the record, access may help patients and their families avoid delays and missed diagnoses by encouraging prompt follow-up of tests, results and referrals.40 43

GPs’ concerns about safety might have been prompted by worries about potential changes to documentation. Akin to recent qualitative studies among primary care staff in England (21) and survey findings from other countries (11, 13 and 26), most GPs (72%, 279/400) in our survey reported they will be/already are less candid in their documentation as a result of patient online access. Such changes may be aimed at preventing patient anxiety, reducing anticipated patient contact and reducing litigation or unintended offence. Nonetheless, after the implementation of ORA, whether changes to documentation do, in fact, diminish the clinical value of documentation is unclear.44 In the survey by DesRoches, 77% (n=188) of primary care physicians perceived no change in the value of their notes for other clinicians; however, 26% (n=63) reported changing how they wrote differential diagnoses.30 In addition, and although not determined in this survey, third-party access or how to protect vulnerable patients might also have been a safety concern for our respondents. Recent qualitative studies in England reported that primary care staff identified patient safeguarding, including for at-risk adults, such as those in coercive relationships, or among vulnerable young adults, as a leading concern.25 26

Finally, supporting recent qualitative research in England, a majority of GPs worried about elevated risks of litigation following the ORA.25 In the USA, to date, we are aware of no medical malpractice cases arising as a result of patient access to their online records. If clinicians make changes that reduce the quality of documentation and this later leads to errors, the risks of litigation might increase. However, if patient access helps increase patient safety by reducing diagnostic delays or medical errors, this could reduce the risk of malpractice since these are the leading causes of claims.45–48

In summary, our survey was in line with recurrent themes in the growing body of international research into clinicians’ views about ORA. However, important contextual factors, including country-specific factors, might have influenced our results. Compared with previously published clinician surveys, the present survey was administered in March 2022, during the COVID-19 pandemic and GP burnout may have contributed to increased cynicism. In the UK, successive governments have advocated a ‘digital first’ model of primary care with ambitious short-term goals for transforming access to health advice, support and treatment using digital online tools.49 50 These policies, accelerated by the pandemic, may have exacerbated GPs’ concerns about work burdens, the rapid adoption of digital tools without adequate training, resources for implementation or consideration of the possible negative consequences of these policies.25

Implications of the findings

Our findings suggest that GPs in England share many similar concerns with their counterparts in other countries where online access to records is now well established. Although few studies have explored patients’ experiences with online access in England,51 we cannot help but observe a trend towards contrastive views between clinicians and patients. Combined, these findings suggest patients in England may be vulnerable to negative stereotyping with regard to their capacity to understand and emotionally cope with reading their own health information.29 Medical ethicists have argued that unfair stereotyping may be used to justify exclusions that further impede patients’ ability to engage in their own care, forfeiting important opportunities to benefit from accessing their documentation.29 52–54 The current study underscores the importance of exploring patients’ experiences in England with ORA.

Notwithstanding, GPs in our survey did perceive many benefits to patients. This is an important finding, given a growing body of research in other countries that shows patients feel more engaged, more in control of their care and better understand their care plan as a result of access to their clinical documentation.18 19 31 34 35 Moreover, in these surveys, as a result of ORA, many patients report greater trust in their clinicians,43 55 a greater sense of teamwork43 and doing a better job taking their medications.34

However, as with surveys in other countries, many GPs believed access would increase work burdens and contact from the patients. Again, studies in other countries suggest that, with practice, these fears may not materialise. Our study highlights the importance of supporting GPs and their staff to become better prepared for talking about and writing documentation that patients will now read.56 Equally, patients will require guidance to optimise the benefits and minimise risks. Guidance materials should be aimed at supporting GPs and patients to better partner with each other and to promote engagement with care plans while raising awareness about GPs’ work burdens.

Strengths and limitations

This is the largest survey conducted in the UK on doctors’ views about patient access to their online health records. Given the ongoing changes to default online patient record access, the survey is timely. However, the study has several limitations relating to the use of a non-probability sample and a limited sample size. Although we strove to stratify the sample as far as possible according to geographical location, gender and age, our respondents were restricted to those GPs who use Doctors.net.uk and who used the service during the administration of the survey. In addition, we did not collect data on whether GPs worked part time or full time or whether respondents were salaried, partners or locums in their practices; conceivably, work burdens might have affected answers. It is therefore not possible to infer that our sample was representative of the opinions of GPs in England. The decision to complete the survey may have been influenced by responder biases such as acquiescence biases or prior enthusiasm or scepticism about the topic, which might have affected the findings. We were also not able to determine the level of patient access to ORA, including that estimated by GPs, using this survey.

We recommend future studies conduct more in-depth analyses of GPs’ ongoing experiences and opinions about ORA. To that end, a follow-up panel survey among participants who agreed to be contacted is planned. Few studies in England have explored patients’ experiences with accessing their online health records. Whether patients in England also accrue the same benefits as patients in other countries remains to be seen. Conceivably, there may be differences in documentation practices or in health literacy between countries, and we strongly recommend survey research in England to explore the views of patients and their families with this practice innovation. As with other countries, further studies are also needed to explore objective changes to documentation as a result of ORA44 57 and to investigate the potential impact on workflow among clinicians following patient access.37