The opportunities and uncertainties of clinic visit recording for older adults

Key Points

• Information exchanged during clinic visits is essential for older adult care, but is not effectively shared

• Visit audio recordings have emerged as a novel strategy to optimise information sharing with older adults

• Recordings are associated with improved recall, understanding, healthcare outcomes in older adults

• Policies developed with older adults to mitigate risks associated with recording are required to realise its full potential

Background

In the United States, older adults aged 65 years and over make 281 million healthcare visits annually. Information exchanged in these visits forms the bedrock of an individual’s care [1]. We outline the benefits and challenges of communicating visit information, strategies to support it, and the rationale for the emerging use of visit recording to improve communication with older adults.

Information overload—Too much, too fast

Patients are expected to discuss and process medical information during the clinic visit and then use it to manage their care at home. This becomes more challenging with ageing. Age-related barriers to high-quality communication exist, such as slower information processing and hearing loss [2]. These issues are compounded by the widespread presence of multimorbidity, which leads to a large volume of complex information and the need to remember a list of self-care activities, such as managing medications and coordinating care with multiple clinicians [3].

The information gap impacts care partners’ role and well-being

Incomplete information also impacts care partners, family, and friends who support older adults in their care. Forty-two million Americans assist with care for adults >50 years of age, and 89% are family members [4]. Care partners advocate for patients, share information with family members, and assist with self-management. Care partners’ preferred source of medical information is directly from the patient’s clinician, yet they often cannot attend the clinic visit; 84% of care partners report needing more information to support the patient [5] such as medication regimens. A lack of information about the patients’ care lowers preparedness for care partners, leading to higher care partner stress and morbidity [6].

Traditional strategies to support effective communication of visit information fall short

The US Medical Expenditure Panel Survey reveals older adults with multimorbidity report decreasing communication quality [7]. Clinician strategies, such as checking understanding (i.e. teach-back) and restating information, can help patients process and store information, yet, depending on training and time available often fail to happen. The last two decades have seen significant efforts to increase patient access to visit information in the United States. Patients are offered an after-visit summary of the clinic visit generated from the electronic medical record. It includes diagnoses, medications, allergies, and clinician comments [8]. In 2021, the 21st Century Cures Act required healthcare organisations to provide patients with direct access to their electronic health information. However, summaries and notes in the medical record are not oriented to the patient, and often fail to capture the rich exchange in the visit, and medical jargon is common, associated with the reduced trust of older adults in their clinician [1, 9, 10]. A review of visit notes from practices across the U.S. found that key information, such as goals of care and treatment instructions were often absent [11].

The emerging use of healthcare visit recording to support older adults

A complementary strategy to augment visit notes is the emerging sharing of visit recordings. Recording clinic visit recordings involves using a recording device to capture audio of a clinic visit which is then shared with a patient to listen at home alone or with a care partner. Recent advancements in generative AI allow the automated documentation of clinic visits directly into the medical record based on ambient visit recordings with demonstration projects underway across the U.S. [12] Routine clinic recordings are on the horizon, but what does this mean for older adults and their care partners?

The benefits of sharing visit recordings

Systematic reviews find that visit recordings increase patient understanding and recall and improve self-management, especially in older adults [13]. In contrast to written notes, recordings capture the clinician’s counselling and recommendations verbatim. Recordings also increase patient confidence in treatment and reduce the number of phone calls to the clinic [14]. Recordings have also been proposed to mitigate the information gap reported by care partners [13]. Patients and care partners can listen to the recording multiple times and in a place where they are most comfortable. Patients report using the recording to clarify information communicated during the visit, and to evaluate the quality of their communication [15]. With access to recordings, care partners feel engaged in the patient’s care and better prepared to support it, especially those who cannot attend visits. Clinicians report that initial concerns about being recorded are often assuaged once it becomes routine. Both patients and clinicians report a sense of higher-quality interactions; they attribute this to a shared sense of accountability and greater preparedness as patients often re-listen prior to upcoming visits [16].

Concerns are minimal, but potential harms must be proactively addressed

Concerns exist about data security and possible liability, yet medical and legal experts report that recording may also protect clinicians. This is echoed by malpractice insurers in Arizona, which have offered clinicians a reduction in malpractice premiums and an increase in coverage if they record [17]. We also must monitor for unintended harms of visit recording in older adults. For example, with access to recordings, care partners may attend fewer clinic visits, leading to greater isolation and loneliness in older adults. Visit interactions are also situations where people are at their most vulnerable, sharing intimate details about their lives. While recordings do not appear to impact the sharing of such sensitive information, ensuring the security of this information is of paramount importance [16].

Preparing older adults for a future with visit recordings

Sharing recordings of visits is an opportunity to close information gaps and provide actionable, patient-centered visit information for older adults and their care partners. The emergence of sophisticated AI applications powered by recordings presents additional opportunities (e.g. reducing diagnostic errors, documentation burden, and improving patient-centered communication) and risks (e.g. exacerbating biases, increasing patient burden, and costs without benefit) beyond the scope of this editorial [12, 18]. Ensuring consent to record and transparency related to who has access to visit recordings must be regularly reviewed with patients. In the case of older adults, advanced directives related to posthumous data use should be considered, as the visit recording is unfiltered and likely retains information related to family and friends, some of which may continue to be sensitive and protected [19].

Recording is not the panacea for all challenges related to communication for older adults, and it will also come with its own practical, legal and ethical challenges. Only through the ongoing and meaningful involvement of older adults in research and real-world implementation of recording can we realise the full potential and required protections in this evolving healthcare landscape [20].

Declaration of Conflicts of Interest:

None declared.

Declaration of Sources of Funding:

Drs Barr, Masel, and Cavanaugh’s research reported in this publication was supported by the National Institute on Aging of the National Institutes of Health under award number R56AG061522, R01AG074959, and through a Patient-Centered Outcome Research Institute (PCORI) award (HA-2021C3–24754). Dr. Barr was also supported by the National Institute on Aging of the National Institutes of Health under award number R01AG077113. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health, or the Patient-Centered Outcome Research Institute, its Board of Governors or Methodology Committee.

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