Medical support for open notes grows over time, with warnings


Although most physicians surveyed expressed doubts about sharing clinical notes with patients before they did, a new longitudinal study finds that their perspective has changed dramatically with experience.

The conclusions, which come just weeks after federal law began requiring doctors to share notes with patients, they were published online on April 22 at Journal of General Internal Medicine.

James Ralston, MD, MPH, and his team at the Kaiser Permanente Washington Health Research Institute in Seattle, Washington, analyzed the responses of 192 physicians (119 in primary care, 47 in medical specialties, and 26 in surgical specialties). Patients were invited to view their visit notes online in 2014 and again in 2018, 15 months after an open notes program was widely implemented in the Kaiser system.

Prior to implementation, 29% of physicians agreed or somewhat agreed that making notes on clinical visits available online benefited patients in general. After compensation, this percentage grew to 71% (Pg <.001). Also, 44% of doctors went from thinking it was a bad idea to thinking it was a good idea. Only 2% went from thinking it was a good idea to thinking it was a bad idea (Pg <.001).

Attitudes changed after implementation in all categories of physicians.

“I think the overall message is positive: it will probably have less impact on your practice than you think,” Ralston said. Medscape Medical News.

The number of people who care about time calls for falls

The proportion of doctors concerned about increasing office visit time fell from 47% before implementation to 15% after. The percentage of people who thought more time would be needed for patient questions fell from 71% to 16%. Similarly, prior to implementation, 57% thought it would take longer to produce the notes; after implementation, 28% thought so.

Beliefs that patients would have greater control over their care were strong to begin with and increased slightly, from 72% to 78%. In contrast, the beliefs that patients would care more about if they could see the notes decreased slightly, from 72% to 65%.

Both before and after implementation, most clinicians said that sharing notes made their notes less sincere (65% vs. 52%).

The authors report that the pattern of change was similar among primary care physicians, medical specialties, and surgical specialties.

Changing landscape

Ralston and colleagues point out that patient responses have always been positive. For example, patients report that they are better prepared for clinic visits, that they have a better understanding of their care plan, especially medications, and feel more controlled by their care.

But few studies have evaluated physicians ’opinions over time, and much work remains to be done to make open notes valuable and effective.

In some areas, confidence in note sharing declined significantly.

Prior to implementation, a higher percentage of physicians reported that patient satisfaction and safety would improve (40% and 33%, respectively). After implementation, 17% and 11%, respectively, felt this way.

“To realize its potential to improve safety, quality, and care experience, it may be necessary to gather open notes with additional interventions,” the authors write.

Mental health physicians are not included

Among the limitations of the study, the authors note that they did not include mental health clinicians, who may have more concerns about open grades.

Steven Reidbord, MD, a psychiatrist in a private practice in San Francisco, California, said adding mental health experts may have altered the results of this study.

“Mental health clinicians need to be more concerned, not only with the motivation of patients looking at their notes, but also with what they are able to conclude,” he said.

Reidbord, for those who blog Psychiatry today, he said Medscape Medical News he doesn’t think sharing notes is bad and that patient engagement is always good. “I don’t think it helps anything. It’s a measure to feel good,” he said.

Reading clinical notes is not the best way to involve patients in their care, he said. He noted that clinical notes are often technical and are usually full of slang.

It was more helpful, he said, that patient-directed literature would be more helpful in helping patients, “not the product of the work of doctors trying to get the job done.”

He continued: “Transparency is good. It’s a poor tool for doing that.”

Open notes are probably best suited for primary care, he said. He agrees that it is good to know from this study that most doctors made sure that open notes did not increase their workload or visiting time.

When asked about falling doctors ’belief that open grades would improve patient safety or satisfaction during the study period, Ralston said the likely explanation is that the number of patients who read notes was less than they had expected.

“We had 10% to 11% of our grades read,” he said. “We waited until we had 11 continuous months in which 10.5% of the notes were read, and that only happened after we started sending patients an email notification that they had a note ready to review.”

This can undermine one of the purposes of open notes, as if patients do not read the notes, they will not point out mistakes and ask questions that may improve safety and quality.

Reidbord said that if patients do not read the notes, it feeds the question of the value of open notes.

In addition, 74% of physicians surveyed reported that the value of their grades to other physicians remained the same before and after implementation, “with a quarter (25%) reporting a much lower or slightly lower value. “, say the authors.

“It’s something else that doctors have to do that doesn’t really help healthcare,” Reidbord said. “Notes aren’t for public consumption, especially. Don’t go to a restaurant and ask the chef to look at their recipes. It’s no secret, it’s just not part of the experience.”

The survey was funded by The Health Group, Robert Wood Johnson, Gordon and Betty Moore and Change Health Foundations. The authors and Reidbord have not disclosed any relevant financial relationship.

J Gen Intern Med. Published online April 22, 2021. Full text

Marcia Frellick is a Chicago-based freelance journalist. She has previously written for the Chicago Tribune and and was editor of the Chicago Sun-Times, the Cincinnati Enquirer and the St. Cloud (Minnesota) Times. Follow her on Twitter at @mfrellick.

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