On April 5, 2021, the federal government mandated that health care providers provide free electronic access to patients’ clinical notes, as part of the 21st Century Cures Act. This includes 8 types of notes spanning outpatient and inpatient arenas. If providers/organizations do not comply with this mandate, they will be subject to fines due to “information blocking.”
This was borne from the OpenNotes movement – which declares itself to promote and study transparent communication in health care by sharing notes with clinicians and patients. They hypothesize that with increased patient access to notes – quality and safety of care will improve. They suggest patients reading their own notes will “add a second set of eyes.” But is that the way we want to shape health care? How did we get to a point where patients are now the targeted audience of clinical notes?
The first signs of a modern medical record started in the early 19th century in Paris and Berlin. These written records involved recording disease states and remedies primarily for advancing the treatments in medicine. It became clear to practitioners that keeping a record improved medical advances as well as patient outcomes. At this point, the record was kept by and for clinicians for the purpose of providing improved care.
Fast forward to the late 19th century – the delivery of health care changed. With the creation of Medicare and Medicaid came a dramatic increase in health care spending. Various regulatory departments (utilization, coding, quality, etc.) were thus created to address these rising costs. The medical note, which was now shifting to become electronic, was a targeted way to track these changes. For example, utilization is a department that is born out of rising medical costs. This department was tasked with looking at how health care “utilizes” services. Providers would need to document the justification of why a patient needed a certain test like an MRI instead of an X-ray, a medication when others were available, a hospital stay instead of an outpatient visit, etc. These new requirements of documentation caused the medical note to shift once more. Now kept by physicians not only to provide care but to track the effectiveness, utility, and quality of care provided.
Now – we are shifting the purpose and audience of the medical note even further. Notes have already become an increasing point of contention and cause of burnout for physicians. Less time is spent with patients, and more and more spent next to a computer. If patients now have open access to all notes, how will this change the content and purpose of the medical note even further?
I have watched my organization send out information about how to comply with this new policy. Providers have been educated on this change and told that it should not change the workflow or content of a note. But is that realistic? I had a patient come in for weight loss recently and considered cancer as a differential. But I found myself hesitant to write this in a note that my already anxious patient could immediately see. I considered this could be due to a thyroid condition rather than malignancy, but I was trained to consider every possible differential. The differential and the medical note is a large portion of the art of practicing medicine. There is immense value in it. This point was ingrained in me throughout my medical training.
If OpenNotes does, in fact, lead to a change in the way physicians document, what could be the downstream effects? The quality of care may suffer. Some providers may choose not to include information they feel the patient may perceive in a negative light. This may be to persevere the doctor-patient relationship or to avoid negative patient satisfaction – which doctors are already tracked on. Some may be hesitant to include information they normally include to convey to other treating providers. For example – a patient with suspected drug-seeking tendencies or family members suspected of secondary gain? Within OpenNotes regulations, exceptions are noted for psychiatric notes, and notes that the physician believes are likely to cause harm to the patient. What constitutes harm seems unclear, and if providers do not comply with this rule, they will be subject to fines due to “information blocking.”
Ultimately, if we devalue the documentation aspect of patient care well then, patient care will suffer. While I understand the need for health care transparency and the possible benefits of increased coordination and health care literacy – I can’t help but feel the pitfalls have not been properly addressed. With each change in health care, it is difficult to truly anticipate the downstream effects it causes to the industry. Time and time again, we have put forth further regulations from outside bodies to “improve care” that have led to anything but. Now in a predictable fashion, health care providers must comply with further regulations dictating the way in which they provide care – and who can be surprised.
Sneha Tella is an internal medicine physician.
Image credit: Shutterstock.com