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The CHRONICLE Trial. Comparing Healthcare Visit Recording and Open Notes to Improve the Chronic Illness Care Experience for Older Adults

Funding Source

Patient Centered Outcome Research Institute (PCORI), 24754

Project Period

11/01/22 - 10/31/27

Principal Investigator

Paul J. Barr, PhD, MPH (PI; Geisel School of Medicine at Dartmouth), Kerri L. Cavanaugh, MD, MHS (Vanderbilt University Medical Center), Meredith Masel, PhD, MSW (University of Texas Medical Branch)

Other Project Staff

Team Members: Martha Bruce, PhD (Department of Psychiatry, Geisel), Elizabeth Carpenter-Song, PhD (Department of Anthropology, Dartmouth College), Cait DesRoches, DrPH (Harvard), Craig Ganoe, MS (CTBH), James Goodwin, MD (UTMB), Parul Goyal, MD (VUMC), Alberto Gutierrez, MD (UTMB), Hynouk Hong, DO, MPH (Dartmouth Health), Sunil Kripalani, MD, MSc (VUMC), Bill Nelson, PhD, MDiv (Geisel School of Medicine), James O’Malley, PhD (The Dartmouth Institute), Lisa Oh, MS (CTBH), Isamar Ortiz, BA (UTMB), Trent Rosenbloom, MD, MPH (VUMC), Susan Tarczewski, CCRP (CTBH), Sonya Williams, BSN (VUMC), Adam Wright, PhD (VUMC). Patient Partners and Stakeholders: Roger Arend, BSCE (Patient Partner), Kathleen Cameron, BSPharm, MPH (National Counseling on Aging), John Donnellan, MPA, FACHE (NYU Wagner), Carmen Juch Gore (Patient Partner), Larry Gore (Patient Partner), Robert Kottkamp (Patient Partner), Ellen Flaherty, PhD, ARNP (Dartmouth Centers for Health and Aging), Kelvin Jones (Patient Partner), Nancy Lundebjerg, MPA (American Geriatric Society), Manuel Ortiz (Patient Partner), Tiffany Pierce, MD (Medical Executive), Sheryl Piper (Patient Partner), Shirley Green-Reese, PhD (Patient Partner), Michelle Sierpina, PhD (Osher Lifelong Learning Institute, UTMB), Mike Wittke, MPA (National Alliance for Caregiving).

Project Summary

Patients forget up to eighty percent of clinic visit information immediately post-visit. This is a significant barrier to self-management, especially in older adults with multimorbidity leading to poor health outcomes. Patient portal access to written visit notes and summaries is now standard and can improve recall and health outcomes, yet concerns exist about their layout, accuracy, and low patient uptake. A growing but underutilized strategy to augment notes is to share visit recordings with patients. When patients receive an audio recording of the visit, 71% listen and 68% share the recording with a caregiver, resulting in greater recall and improved self-management. Despite growing interest, the most effective approach to communicating visit information to facilitate the management of multimorbidity among diverse older adults living in the community remains unclear. A question has been raised by patients – should visit recording be added to standard practice?


Aim 1. Assess the comparative effectiveness of written visit information provided to older adult patients via the patient portal (NOTES) versus NOTES plus visit audio recording (AUDIO) on quality of life (QOL; primary outcome).

Aim 2. Determine whether patient health literacy, and disease burden, are modifying factors on the comparative effectiveness of NOTES versus AUDIO on patient QOL.

Aim 3. Identify system and patient-level factors that impact the implementation and use of multimodal strategies of healthcare visit information exchange by patients, caregivers, and health systems.

Hypothesis (Main Effect): Compared to those receiving notes, patients randomized to also receive audio recordings of clinic visits will report better QOL (Primary Outcome), via improved self-management ability, and better treatment adherence, higher quality visit communication, and satisfaction (Secondary Outcomes) at 6 months, with larger relative benefits for those with low health literacy and high disease burden. We will also disseminate specific stakeholder-informed strategies to promote effective visit information sharing and use by diverse populations of older adults and caregivers.

Public Health Relevance

The 21st Century CURES Act ensures that patients and caregivers can access visit information in the medical record – yet it is unclear if this is the best way to share information. Visit audio recordings has emerged as another evidence-based strategy to share information. This has resulted in a decisional dilemma for patients and healthcare leaders who ask the question “what is the most effective approach to communicating healthcare visit information to facilitate the day-to-day self-care of older adults living in the community?” To answer this question, we propose the CHRONICLE (Comparing Healthcare visit Recording and Open Notes to improve the chronic illness care experience for older adults) Trial, a Type 1 Hybrid trial where 900 older adults with multimorbidity will be randomized to receive clinical notes alone (NOTES), or Notes plus visit audio recording (AUDIO) for all primary care visits in a six-month period.

Knowledge gained from our study will improve the quality of evidence about the best strategy of communicating vital health care information in this vulnerable older adult patient population at high risk for adverse outcomes and lower quality of life.