Wise Patient believes in Open Medical Notes

Call it what you want: open notes, open access, patient-accessed, or patient-viewed. We are talking specifically about a patient’s ability to easily access and read the summary section of their medical note, widely referred to as the “Assessment and Plan”, or simply “A&P”. The A&P is a wrap-up summary of the medical encounter from the clinician’s perspective. It attempts to synthesize supporting data (patient’s statements, medical history, physical exam findings, and medical tests) with medical knowledge to create the most cohesive medical conclusion possible and a medical roadmap for the patient to follow forward. How many of you, outside of my own patients, regularly read your doctor’s Assessment and Plan? Our guess is 20%, tops, and that is the problem. The traditional audience for the A&P is anther physician – the same doctor next appointment, the sub-specialist, or the ER doctor on staff when the ambulance rolls up. But not you, the patient. You, traditionally, get a curtly-typed or even hand-written layman’s to-do list: start this medication, stop that one, go for chest x-ray, ice this, eat better, exercise more, etc. The greater details are left up to your memory of your conversation with your doctor or what you absorb from a one-size-fits-all educational handout published by a third-party.

Our position is straightforward. I believe in open medical notes. We write each Assessment and Plan for two audiences: my patient and my patient’s other doctors.

The medical literature that exists on this topic – not much – supports us. A groundbreaking study on open medical notes, funded by the Robert Wood Johnson Foundation, was published last year. In fact Harborview Medical Center here in Seattle was one of the 4 hospitals involved and two local physician researchers, Joann Elmore (UW) and James Ralston (Group Health) were among the authors. The results reflected well on open medical notes. Here is the first paragraph from the Discussion section of the publication:

Patients were enthusiastic about open access to PCP visit notes; 99% of those who completed surveys recommended that this transparency continue. Overall, a large majority opened some or all of their notes, and almost 90% believed that open notes would affect their decisions when seeking care in the future. The vast majority reported an increased sense of control, greater understanding of their medical issues, improved recall of their plans for care, and better preparation for future visits. Perhaps most important clinically, a remarkable number reported becoming more likely to take medications as prescribed. In contrast to the fears of many doctors, few patients reported being confused, worried, or offended by what they read.

Yet, according to an Accenture survey published this month, only 31% of U.S. doctors believed patients should have full access to their electronic health record and only 21% said they currently allow patients online access to their Assessment and Plan.

We are familiar with the assertions against open medical notes. Most relate to patients with anxiety or mental illness, patients who are litigious, or doctors lacking the time needed to strip the Assessment and Plan section of their note of medical jargon and abbreviations. These concerns are valid for a small portion of patients, though my general experience is that effective communication improves anxiety, corrected power imbalances lower the risk of lawsuit, and empowered patients are able to assimilate most medical jargon and abbreviations.

At Wise Patient, we have given all patients full online access to the Assessment and Plan portion of their medical note from every appointment, from day one. We have not been able to do that in my past work environments. The overall effect could not be clearer. Our patients have gladly accepted our invite into the central command room of their medical strategy. They have gained medical knowledge, medical confidence, and a more balanced sense of medical evidence. They understand our training and thought processes better. They appreciate seeing that their medical plan has accounted for the values and preferences they bring to the table.

If you agree with us that the overall benefits of open medical notes outweigh overall risks of them, http://myopennotes.org  is a solid resource for the cause.

Transparency in healthcare is the way forward. Open medical notes makes me a better doctor and my patients healthier people.

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