5 clinician concerns about OpenNotes

More than 200 health organizations have now implemented OpenNotes. Many more are piloting, are soon to implement — or have implemented, and we don’t know it! For more than three years I’ve been fortunate to represent OpenNotes to potential implementers, and I’m confident I’ve heard almost every clinician concern or anxiety regarding what might happen when patients read their own notes.

Here are the five most common concerns I’ve heard — accompanied by why I think you can take a deep breath and direct many of your anxieties elsewhere.

1. “OpenNotes are going to cost too much money because of the EMR …”

While electronic medical record (EMR) vendors don’t support OpenNotes very effectively (for both patients and clinicians), at least they (e.g., Epic, Cerner, Allscripts, Meditech) make them available with no additional costs.

To implement OpenNotes, resources needed from a health system’s internal IT group are modest, and technology and/or direct tech expenses are rarely an issue. To be sure, above and beyond what clinicians think of them these days, many EMRs are also not very patient-friendly. But they will get there, particularly when they become more accountable to patients. Bottom line: EMRs are expensive, but those expenses are not a result of the patient-facing features.

2. “Our (fill in the specialty) is going to hate this …”

OpenNotes represents a real change for patients, and even more so for the culture of clinical practice. That’s the biggest obstacle. Patients applaud OpenNotes. Administrators rarely oppose OpenNotes. But some clinicians do, especially physicians.

Our research shows that many physicians are initially anxious, even those who support the general concept. But patients do not share that anxiety. Similarly, behavioral health clinicians worry, but their patients also see transparency as a huge positive. Moreover, creating barriers to transparency in a “behavioral health carveout” is a sign of persistent stigma assigned to mental illness. When it comes to OpenNotes, clinicians caring for adolescents may face the biggest challenge. They need to coordinate the needs of both adolescents and their parents while addressing state privacy regulations.

In summary, for many physicians, we find that OpenNotes is an acquired taste. But overall, large numbers of clinicians in every specialty have come to feel that transparent medical records offer significant benefits to their patients.

3. “Some of our physicians are poor documenters, and it would be embarrassing for a patient to read these notes …”

Such concerns are pragmatic. Some clinicians are indeed less than stellar documenters, have English as a poorly-mastered second language, are afraid of EMRs and associated technology, find themselves suffering from EMR burnout — or all four. Every organization struggles to respond to such challenges, and some are doing so more successfully than others.

I’ve seen lots of anxiety about these issues. But anxiety, when managed constructively, can be productive. For example, some organizations are reluctant to confront poor documenters. I don’t understand this. It’s bad medicine, bad business, inconsistent with the team concept and exposes everyone to risks — especially patients. On the other hand, some organizations have used OpenNotes as an opportunity to raise documentation standards, using it as a potent stimulus for making improvements.

4. “Patients will see we are up-coding!”

Financially troubled organizations see the latest billing software as a way to solve their financial troubles and view that as a priority for all (although they won’t say that publicly). Did the doctor really see the patient for 40 minutes? Was there really a complete physical exam? When patients can see notes, they often recognize up-coding, and some will report it.

It bothers me when part of a business model involves making access to information difficult in order both to generate additional revenues in various ways and to avoid endangering patient loyalty. Our research justifies an opposite approach to helping the bottom line: Champion transparency as a strategy both to build loyalty and attract patients.

5. “My patients can’t possibly understand the notes …”

What saddens me most is clinicians opposing OpenNotes because they believe, or claim to believe that patients aren’t smart enough to understand notes, will be frightened, or will feel unleashed to call, email, or overcome any obstacle that protects the clinician’s private life. We have found just the opposite. We almost invariably underestimate how collectively resourceful patients and families can be, and how careful our patients are to respect their clinician’s time.

It especially disappoints me how often I see this caution articulated by clinicians who serve vulnerable patients and use the “can’t possibly understand” argument to avoid transparent communication. Our vulnerable populations are exactly those for whom we should be doing everything possible, in every way, to convey all the information we have, and help the patients understand it. And our research shows that, once introduced to OpenNotes, it is exactly these patients who report the greatest benefit from this new practice.

Bottom line: In our research, patients rarely report being confused by reading their notes. And those who are economically and socially disadvantaged especially value this transparency.

Finally, my best days come when I find clinicians who realize their impact will be maximized when the focus moves beyond face-to-face care. Need and demand for information exceeds any possible face-to-face strategy, and that means we have to become open to more creative information strategies that entail less clinician control and more patient autonomy and engagement.

Some clinicians assume such loss of control means more work and risk. It shouldn’t. All the good social science I see suggests that patients trust clinicians more than anyone else (all clinicians, not just doctors). And our research at OpenNotes suggests the same is true for the information offered by clinicians through their notes.

Patients are savvy. They trust, but want to verify…and when they do, trust increases even more. And that’s a wonderful experience. Try it.

John Santa is director of dissemination for OpenNotes, Beth Israel Deaconess Medical Center, Boston, MA.

Image credit: Shutterstock.com

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