What is the Purpose of Doctors' Notes?

The question of whether patients should have unlimited access to their medical charts and doctor’s notes.   At first glance, the answer is a robust “YES”, after all it is about (me) the patient, therefore it is (my) the patient’s ‘right’ to have complete and unhampered access.

Actually though, it is highly unlikely most non-medically educated patients really wouldn’t understand the language in their progress notes.  It’s not usually a matter of whether or not they can read the notoriously horrible penmanship of the physician, since the notes are dictated verbally by the physician and then transcribed by a trained medical transcriptionist who has put in many long hours learning the medical terms, acronyms, and “doctor-ese” abbreviations.
 
The US Department of Health and Human Services (HHS) in the Health Insurance Portability and Accountability Act (HIPAA), describes patient’s right to medical information:
“The Privacy Rule gives you, with few exceptions, the right to inspect, review, and receive a copy of your medical records and billing records that are held by health plans and health care providers covered by the Privacy Rule. “  The rule allows up to 30 days for those records to be given to patients and allow charges to be assessed for copying and mailing expenses.
Patients have had the right to access to their medical records since 1996, but few avail themselves to the information.

Researchers are launching a pilot program, “OpenNotes” attempting to improve doctor-patient communication with the use of the internet.

The OpenNotes project is demonstrating and evaluating the impact of sharing encounter notes between patients and their primary care physicians (PCPs) online.

The study is being conducted at Beth Israel Deaconess Medical Center in Boston, Geisinger Health System in Danville, Pennsylvania, and Harborview Medical Center in Seattle. It is supported by a major grant from the Robert Wood Johnson Foundation Pioneer Portfolio, and supplemented by grants from the Drane Family Fund, and the Katz Family Foundation.

 Included in the program are 100 primary-care doctors in MA, PA and WA who will participate in the 12 month test period starting this summer and approximately 25,000 patients sho will have access to their medical records including the physician notes.

As the general trend toward transparency accelerates, hospitals and health care systems with electronic medical records increasingly allow patients to view laboratory results, medication lists, and other parts of the medical record.

However, though patients own their medical records, they rarely have easy access to the notes written about them by doctors and others. OpenNotes is a simple, but potentially disruptive intervention that aims to transform the patient-clinician relationship as it furthers both transparency and the democratization of health care.

During the 12 months of the study, patients are invited to read the notes their PCPs write following office visits, e-mail correspondence, and phone calls. They can view these notes in their medical records via the secure websites where they can also view other portions of their medical records.

Once the PCP writes and signs a note after an encounter, the note is "opened," and patients receive an e-mail message announcing its availability. Shortly before his/her next scheduled appointment, the patient receives another message suggesting that s/he review the note in preparation for the visit.

Information to be examined include utilization during OpenNotes to utilization in the 12 months before the project, and comparison of patterns among OpenNotes participants and non-participants. Did the numbers of primary care visits, specialist referrals, and emergency department visits change?

Both participating PCPs and patients to will be encouraged to comment, offer anecdotes, or even write stories about their experiences.  In-depth interviews with a number of participants will be conducted near the end of the project asking: “How did patients feel about reading their notes – did it change their attitudes or lead them to change behavior?”  “How did OpenNotes affect doctors – did it change how they wrote notes? Did it affect their patients?”

A frequent objection expressed by doctors is how much this approach would take away from their patient diagnosis time.

"They were most worried about what this would do to their time, worried that they'll be swamped with questions from patients," said study co-author Jan Walker, an instructor in medicine at Harvard Medical School and Beth Israel Deaconess Medical Center in Boston.

It’s possible that A lot of time-consuming interactions that currently to take place on the phone may become obsolete by patient’s logging onto secure Internet portals.

There is also concern that patients might not understand much of the information in the physician notes and become alarmed when they see certain words such as cancer, diabetes, heart disease which are not part of the diagnosis, but are reference words for the physician as he works toward a diagnosis.  Patient’s may also become upset or even angry when faced with words like obese, substance abuse or sexual activity. 

This could force physicians to express themselves and describe their patients more clearly and carefully in their notes. 

The medical chart is a concise record containing physician’s notes, lab test results, medical tests and outcomes, patient history, family history, hospital history and the most sensitive information concerning the patient seem almost a sacred mystery to most.
 
It is also the most valuable tool between physicians when sharing a patient, or when a patient moves from one area to another and chooses a new health care provider.  The medical chart is like a diary of all the pertinent information that physician needs to form an informed relationship with the patient. 

A Medical Transcriptionist from OH says with a chuckle, “I’ve been transcribing doctor’s notes for 16 years and have never had a doctor dictate any deep dark secrets, gossip or use disparaging words in the patient description. “  She also believes that (personally), it’s more important for her medical charts to be easily read and understood by health care professionals who need quick access to possibly life-saving information, than it is for her to understand all of the medical lingo.

 The "bottom line" evaluation of OpenNotes is straightforward:  Will patients and doctors want to continue when the study period ends?

Laura Lamp King