A physician responds to OpenNotes critics

There is a growing group of articulate and engaged patients committed to getting access to all their medical information in order to be better positioned to work collaboratively with their clinical teams. Published studies like the OpenNotes project have consistently shown significant benefits and a lack of serious problems. Health care systems are slow to change and just beginning to understand both the need and value to this more transparent and collaborative approach.

My institution, for example, is not ready (or even interested) in anything approaching opening chart notes to patients. In fact, although our secure portal will be launched in the near future, there was some resistance to making even problem lists, medication lists, lab and x-rays available through the portal.

That need not prevent individuals from contributing to change. A few years ago I began providing every patient with a copy of their office visit note as they left the office after their visit. The intent was for us to do the assessment and plan collaboratively and make sure they have a copy of our (collaborative) plan.  Patients have been very appreciative, and use it to share the assessment and plan with family and consultants, and as a reference. A few bring it back at the next visit with notes on it about what they did and what happened.

To the objectors who say that one cannot be honest in a note if the patient is going to see it, I say: balderdash. (Actually, what I say is much stronger.)  For one thing (the smaller point) the patient is already allowed to see it if they but ask.  More importantly, this argument depends entirely on the principle that the clinician knows best and needs to keep secrets in the interest of the patient.

What I have experienced is a variation on the advice I got many years ago regarding relationships: If it’s important, then it’s important enough to be open about and deal with. If you aren’t willing to deal with it openly, you are not allowed to save it up and spring it on your partner (patient) later.

I have found that it changes the nature and quality of conversations about difficult topics. First, it means I have to be objective and neutral about the issue, separating ‘my’ stuff from the mix. I can’t get away with labeling a patient in my chart as a symptom magnifier or minimizer, having poor insight into their contribution to the problem, describing pain that does not fit with the setting or findings, making poor choices, non-compliant.

Instead I have to describe what I am seeing and why I find it important or of concern. This generates good (and trusting) conversations — and progress.  More than a few patients have commented, “I like that you put that on the table — I can tell when my x-ologist isn’t being straight and it pisses me off.” Clinicians who think patients can’t tell are deceiving themselves.

I have not found psychiatric or social issues to be much of an exception. In fact, I have been surprised at how often this approach has been the key to successfully addressing psychosocial issues.

The biggest challenge has been the patient with a sensitive problem (think about a 16-year-old there for ? chlamydia) whose friend or relative may be in the waiting room.  The solution has been simple: “Don, just to be clear, I usually give patients a copy of the note we do, but if you’d rather not, just say so. Or I can print it and go get it and give it to you here instead of at the front desk.”

There have been some issues. A few consultants complained that they are getting pressure from my patients to do the same. (I simply said, tell me if it is a big problem and I will send my patients elsewhere. That was the end of it.)  I feel obligated to spend time every morning before my day starts “cleaning up” the chart. The pre-visit work actually serves two purposes, and while it is work, I can’t imagine not doing it. I can review the reason for the visit, collect and copy/paste or abstract important pieces into the note (this helps us at the visit and the patient at home later), find errors, clean up (remove the penicillin from last year’s strep throat from the med list), and look for things for which the patient is eligible (mammogram, Tdap) or problems that have been lost to follow up (gout, on allopurinol, no creatinine or uric acid in 18 months). This work significantly improves my ability to focus on the patient and our work during the visit.

And, I would be remiss if I failed to mention accuracy.  In addition to narrating what I am typing so patients can correct it, (“No, the pain started two weekends ago, not last weekend,”) patients call to fill in the blanks or correct errors. Lots of great family history and details about previous medical events become part of the record.

From my perspective, framing it as whether or not the record/note is open misses the point. The point is, the collected information, assessment and plan that the patient and clinician are basing diagnosis and treatment on should be used as a collaborative tool, not as the clinician’s private record of why they did what they did (to the patient).  That’s called a diary, not a medical record.

Peter Elias is a family physician who blogs at his self-titled site, PeterEliasMD.

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  • http://www.mightycasey.com/ MightyCasey

    THIS is how primary care should be done. Full disclosure: Peter Elias is a friend.

    I really wish we lived in the same city, but the good news is that the new MD at my primary care practice is following the same “share the visit note” protocol – in my most recent visit, in the last week, she handed me the note before I left. It was clear, outlined the next steps and plan, and all the me-specific data was correct. WIN.

    As ePatient Dave says, “People perform better when they’re informed better.” Health literacy starts with understanding what’s happening with one’s own corpus. A great doc helps one do that. Peter Elias is a great doc. We need more like him.

  • http://blog.stevenreidbordmd.com/ Steven Reidbord MD

    Patients already have the right to see their medical record. The question is whether establishing this as routine practice is beneficial for patient care. In my opinion it offers certain benefits, but on the whole it is “good intentions gone awry.” I explain why here:

    • guest

      Excellent post.

  • Kaya5255

    Full disclosure of EVERYTHING in the record. Anything less, is unacceptable.
    When I hire a lawyer, I pay for and expect full disclosure. When I hire and pay for a mechanic, I expect full disclosure.
    I hire and pay for a physician, I not only expect full disclosure, I demand it.
    If you label me as non-compliant or uncooperative, you will receive a challenge to that, which in NYS will be part of the record.
    For far too long physicians have been controlling and paternalistic.
    You absolutely cannot have it both ways.
    Hehalthcare consumers have the final decision-making authority.

    • http://blog.stevenreidbordmd.com/ Steven Reidbord MD

      When you hire a lawyer, you never get “full disclosure” of his or her thinking process. Likewise a mechanic: “I usually torque the head bolts to 30 ft-lbs in an alternating pattern, but this is one of those Chevy small-blocks, so I torqued hers to 35 instead.” Also, “I planned to finish her car this afternoon, but my long-term customer came in with a simple oil change, so I pushed hers back until tomorrow morning.” Everyone you hire makes countless decisions you are not privy to. Troubling or not, it’s a simple fact. You already have the right to see everything in your medical record, which is crucial if you suspect malpractice or ill-will. But in my opinion proposals to establish routine disclosure of medical work-flow (which is what a “visit note” really is) stem from an UN-trusting environment, as suggested by the tone of your comment.

      I do everything reasonably possible to demonstrate my integrity and trustworthiness as a doctor. But if a patient comes in already assuming that I lack integrity and cannot be trusted, I’d prefer they go elsewhere and find a doctor they are at least open to trusting. I’m sure lawyers and mechanics feel likewise.

  • Karen Ronk

    This is a fantastic way to create a more trusting environment with your patients. And as the article points out, it is a good tool for correcting factual errors that can make a difference in treatment and taking personal opinions not based on facts out of the equation. Perhaps some further tweaking of the ACA could focus on gradually implementing this practice throughout our medical system. Not holding my breath though.

  • T H

    I agree that patients should be able to get the entirety of their medical records.

    They should not be able to change or amend their medical records. Submit a statement/rebuttal? Perhaps, but if I say someone has syphilis, then why would I not put that in as part of the history, esp. if there are neuro complaints? And not everyone is going to be comfortable with ‘syphilis’ in their medical record… especially when their partner says “Hey, honey? Mind if I take a look?”
    No matter what, there’s not going to be a good answer.

  • Ladyimacbeth

    If they cannot stand behind it, then they shouldn’t write it.

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