After I had a surgery a couple of years ago, I requested a copy of the discharge summary to add to my records.  It was no surprise that there were a couple of errors.  “Would you like information on quitting smoking? –what??!!”  A template entry error suggested that I smoked,  explaining why a well meaning nurse gave me some confusing counseling.  I found a few other slight variations from reality in my interviews with several providers.

This morning I jogged to a Annals of Internal Medicine podcast discussing a recent article, “Open Notes” a description of a pilot project being done by 100 physician and 25,000 patient volunteers.  In this upcoming project, patients will receive an email after clinic visits allowing them access to their clinical progress notes.

This type of access shouldn’t be particularly shocking.  Patients have legal rights to review notes.  But… the system doesn’t make it easy - there are obstacles-  some are human, and some are technical.  However in many settings we have increasing collaboration between doctor and patient (evisits are collaborative) to create documentation.  Patients have access now to many parts of their record.  Many physicians are putting assessment and plan documentation into a visit summary that patients may take home on paper, or review on line.  This is important because we know that only about 1/2 of what is heard is recalled correctly by patients in the course of a sometimes stressful, and often hurried clinic visit.  But what about the other parts of documentation- the medical history and the physical findings?

There is an obvious advantage to open notes- getting the facts correct!

…if there’s any correction that needs to be done or miscommunication, it can get straightened out right away…I think [allowing patients to read their doctors' notes] is going to make things a lot better in the long run. - An engineer patient, quoted from the Annals article

Pros and Cons?

Physicians worry about many calls or emails about clarifications for trivial errors or technical phrases (”patient is SOB” = short of breath?); Some thought their notes would need to be less precise; Some where embarrassed about their writing style.  Doctors also worry that patients would draw inappropriate conclusions - becoming cardiac “cripples” or worrying about cancer from a few speculative words.

On the other hand, benefits include efficiencies in communication, beneficial clarifications, and more patient and family engagement. - powerful.

Patients are also ambivalent.  Patients also worried about hearing something they were not ready to know, or hearing what the doctor was thinking about  them, or something that would shake confidence.  But open notes seem to many patients like a next logical step in heath care transparency with benefits parallel to those seen by doctors- accuracy, engagement, collaboration…

Discussion in the podcast speculated about whether doctors would learn to document with different words.  Words like “obesity” have specific clinical meaning but are socially charged.  I might use more plain and descriptive language…. overweight, high (or low) risk?  Would doctors use “private notes” for the occasional need for personal speculation? -maybe sometimes.  Notes are more frequently templated - capturing discrete factoids vs narrative of the past- is this good?  Dr Delbanco, lead author, anticipates that notes will become more collaborative and even signed by both participants as a sort of contract for care.  This sort of disruptive change, may open the door to many unanticipated changes!

John Butler MD