Are docs ready to open up to the idea of clinical note-sharing?

Sometimes I feel bad for doctors.

Wait--stop laughing and hear me out.

Although the public at large tends to hold great respect for physicians, within the healthcare industry they get the blame for a host of problems.

Under Meaningful Use, they're held responsible if patients don't take an active interest in their own health data. If patients don't take care of themselves after discharge and get readmitted to the hospital within 30 days, they get penalized under new healthcare payment models.

And, let's face it, when there's a problem with almost any kind of technology implementation--from electronic medical records to computerized physician order entry systems--they get the blame for that, too. To hear many health IT professionals (and other folks) talk, you'd think physician adoption of technology was as intractable a challenge as handwashing compliance.

The practice of medicine has been dramatically changed with the increasingly widespread use of EMRs and computerized order entry and decision-support. Not only do docs have to learn how to use these new technologies, the systems produce reams of data about their practice of medicine, putting unprecedented scrutiny on every decision they make, wrapping it all up in a neat spreadsheet and emailing it to every department head in the hospital.

And now we want to let patients look at their clinical notes? I think it's understandable that some might balk at that.

"The topic generates a lot of strong feelings, a lot of emotions--and that happens on both sides of the examination table," Risa Lavizzio-Mourey, M.D., President and CEO of the Robert Wood Johnson Foundation said at an event in Washington, D.C., last week to discuss results of a year-long open notes pilot. (Available on video.) "I have to admit, when I first heard about this, I was a skeptic, like most physicians."

Physicians are concerned that sharing notes with patients would be yet another burden on their time and that it could confuse or concern patients if they see something in the notes they don't understand. And they worry that with patients looking over their shoulder, they might be tempted to censor what they write.

"Think about trying to explain to a patient that 'SOB' means that they're short-of breath, not that you think they're a difficult patient," Lavizzio-Mourey said.

Danville, Pa.-based Geisinger, Beth Israel Deaconess Medical Center in Boston and Harborview Medical Center in Seattle just completed a year-long study called OpenNotes, funded by RWJF, in which more than 100 primary care doctors invited more than 13,000 patients to see their clinical notes. The results were published last week in the Annals of Internal Medicine.

The study found that reading doctors' notes "does not confuse patients, it didn't impose a burden on the doctors and, most importantly, there's evidence that it actually improves care," Lavizzio-Mourey said. Suffice to say, she's no longer a skeptic.  

Geisinger's CEO, Glenn Steele Jr., M.D., wasn't just an early adopter of electronic health records; he's also an early advocate of open notes.

"As a health system CEO who also is a doctor, I believe it is an ethical imperative that our patients at Geisinger know everything that we know about them. And, I think it's a logical imperative that if we can open up our medical visit notes to our patients, we'll find out what they understand and what they don't, so we can answer questions and work as partners to chart a path to better health," he wrote in a recent RWJF blog post.

The evidence "makes clear that open notes is something patients want, something they use, and something that doesn't unduly burden doctors," Steele wrote. "In fact, it also is something that could lead to better care and potentially could save health care dollars--as many as 70 percent of patients said that having access to their own visit notes prompted them to adhere to the medications their doctors prescribed."

Beth Israel's Tom Deblanco, M.D., the study's co-author, said few doctors reported changes in workflow or longer visits. But, he added, some doctors did change the way they took notes. "Some will have hidden things, some will have avoided things, but my guess is that this kind of transparency, this kind of consciousness of who your audience is makes a big difference," he said. "My guess is that they wrote better notes. I wrote better notes. They were more educational. They didn't take me more time, but instead of saying 'take penicillin,' I would say 'take penicillin because …'"

Further, he said, many doctors said sharing notes strengthened their relationship with patients. And speaking of patients: Fully 99 percent of 6,000 respondents to a survey conducted by researchers said they would like the ability to look at their doctor's clinical notes (even if they might never do so). And 85 percent said the ability to read notes would be important in choosing a doctor or future caregiver.

Another impressive number? "Not one doctor stopped after a year when we offered them that option," said Deblanco. "They didn't all love it. Some of them would have been happy to stop. But I think what happened was they look at their patients, they looked at themselves as said 'this is a one-way track. We can't turn back.'"

Listen, docs are probably resigned to the fact that even people who respect their profession think they're paternalistic, stubborn and, oh by the way, have horrible handwriting—whether any of those things are true or not. But before we heap more blame and criticism on them, let's give some credit to those who are leading the way into a new era of transparency. - Gienna


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