Wednesday, April 9, 2014

open notes

Today our electronic charting system was moved to Open Notes, which will allow patients to access their clinic notes online.

This was not a voluntary transition, nor is it specific to oncology. Notes from all outpatient clinic visits – including cancer counseling (Not considered “mental health”) are now available for online viewing.

I was once told that you shouldn’t write anything into a patient’s medical record that you wouldn’t have to read aloud in court. While this does seem like an extremely “CYA” way of practicing (or at least documenting) medicine, it is still sound advice. Medical records are not confidential and patients have a legal right to them.

But prior to Open Notes, a patient would have to go down to medical records and request a copy of their chart. This took some effort on their part, an effort that might have come about because they felt mistreated or that there had been a gap or misstep in their care.  That is no longer the case – the same records are now available for casual online viewing on the couch for a very different purpose.

The argument for Open Notes is that patients will participate in their care more if they understand the doctor’s assessment of their condition and care plan.  Last night I heard an NPR bit about the difficulties of getting people with low-reimbursement health care plans into see physicians. The story featured a woman in her fifties who had been trying to see a physician for months, and when she finally did was told to stop smoking, modify her diet, and get some exercise. My initial reaction was to wonder why people need a doctor to tell advise them on such basic tenets of personal health. But we, as physicians, are told time and time again that patients who hear “stop smoking” from a doctor are more likely to do it than if they hear it from a friend or family member.

So maybe Open Notes will help get some people engaged in their health, and to understand their “goals” as we see them – LDL, Hgb A1C, prolonged survival without likelihood of cure, etc. But the same studies that show patients engage more when they can read the doctor’s notes also confirm that patients do not react well to seeing “morbid obesity” or “noncompliance” documented in their chart. From a medical perspective, those are important aspects of a patient or his/her behavior that influence why I do what I do. Chemotherapy can be dosed on ideal or actual body weight. If a patient has a history of being non-compliant, I might be more inclined to prescribe neutropenic fever prophylaxis than I would otherwise.  Abbreviations are also a problem - we were asked to use the EPIC autocorrect function to change SOB to read “shortness of breath”.

But I also use my notes to remind myself about the personal aspects of a patient’s life – that their son is getting married next month or that their mother is dying or that that their spouse is not a very good source of emotional support. I suspect I will do less of this type of documentation in the future.

The other reason my group adopted Open Notes is that our competitors are doing the same – a patient’s ability to access their medical record online will become the standard of care in the future and we might as well get used to it now.  Although I have strong suspicion that Open Notes will generate more questions than it answers, and that my tendency will be to write less, I am trying to withhold judgment.

And maybe it will be helpful – maybe if a patient reads that I documented his need to stop smoking, he will take me more seriously. Maybe a patient who reads that I wrote that her marriage is rocky will see I understand she’s dealing with more than just a cancer diagnosis. Maybe fewer patients will claim to have “never been told this isn’t curable” when they read it online.

I don’t know. TBD.

6 comments:

  1. Wow. That's the first I heard of this. It sounds bizarre. I don't write those kind of notes, but I can see the issues that might arise. The document will become less of a doctor's note for their own records and more of a "patient prescriptive." I do like the idea of a patient being able to access what a doctor tells them to do when they go home to their own space and are less intimidated by the weight of the situation. But there should be a place where you can jot stuff down too without the fear of hurting a patient's feelings with brevity, honesty, and medical jargon.

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  4. I sometimes read my notes out loud to the patient to jog their memory on what was previously discussed (esp. because they frequently say- oh, I didn't know that before...why yes I believe you did know that I reminded you to monitor your blood pressure daily and to bring the log with you to clinic)
    and on top of the note, I put it in the patient instructions so they get a print out (they may conveniently lose the print out on the way to the parking lot) but they can't say I didn't go it with them, and give the instructions (after having read it out loud to them while they look over my shoulder).
    yet they continue to say they don't know or remember the conversations!

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    Replies
    1. In all fairness to your patients, I have a difficult time remembering even very simple instructions after I leave the doctor's office, and I'd like to think I'm a pretty cognitively intact, motivated patient!

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  5. We just talked about this in class and small group-apparently, the family practice group at our hospital has switched to Open Note. I'm curious as to how the transition will go-mostly because there are things that are put into notes (like non compliance, obesity, anxious) that will end up causing problems inevitably.

    That being said, it might increase ownership of a patient's health.

    THAT being said, the jargon is so confusion, what do you think of the possibility of patients questioning or getting worried about the descriptors/diagnoses used? A lot of them, when read at face value (I'm thinking of how my mother reacts) are pretty grim sounding when out of context...

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