Blog | Thursday, January 5, 2012

Survey asks doctors and patients if doctor's notes should be in the EHR

We are fast entering the era of the electronic health record, when it will be possible to call up our medical records on our computers and mobile devices. Medication lists, lab results, appointment schedules, they'll all be available with clicks of your mouse or taps on the screen of your smartphone or tablet.

But one question that's far from settled is whether the electronic health record should include the notes that doctors make about them. A doctor's notes can be straightforward, such as a reminder that an additional test might be needed. But they can also include somewhat speculative observations and hunches about a patient and his or her medical conditions. The Open Notes project is a research program designed to test the consequences of giving patients access to doctors' notes. Harvard-affiliated Beth Israel Deaconess Medical Center is one of the test sites.

The Open Notes project is far from finished. But results of a survey of the expectations that doctors and patients have for note sharing are being reported in Annals of Internal Medicine.

I don't think there are any great surprises here. More than half of the primary care physicians participating in the project thought sharing their notes would result in greater worry among patients, and a sizable percentage (36% to 50%) anticipated more patient questions. Yet a large majority (74% to 92%) was optimistic it would improve patient communication and education.

Some doctors at the test sites who elected not to participate in the Open Notes project were also surveyed, and, not unexpectedly, they're less enthusiastic about giving patients access to notes than the participating doctors.

The patients who filled out the survey thought seeing their doctor's notes would have a variety of good effects, like a clearer understanding of their medical condition, improved self-care, a greater sense of control, and so on.

I contacted two members of the Harvard Health Letter editorial board, Drs. Nancy Keating and Suzanne Salamon, and asked them what they thought about giving patients access to doctors' notes. They're on different sides of the issue.

"I'm in the camp that thinks the benefits will probably outweigh the downsides," said Nancy Keating, MD, FACP, an associate professor of medicine and health care policy at Harvard Medical School and an associate physician at Brigham and Women's Hospital.

Dr. Keating continued: "There may be some patients where there are complex issues that could be challenging (like patients with drug seeking behavior), but for the vast majority of patients, I think this is no big deal, and likely very helpful."

"Personally, I don't like the idea of Open Notes," said Suzanne Salamon, MD, who is associate chief for clinical geriatrics at Beth Israel Deaconess Medical Center. "I think that doctors will have to spend a lot of time explaining to patients what they meant if a patient misinterprets. For example, a doctor may see a patient as 'anxious' or 'depressed' or 'obese' or 'alcohol dependent' or 'drug dependant' and the patient may object, perhaps because they don't see themselves that way, or perhaps because they don't want this description in the notes."

Dr. Salamon said doctors may alter what they say in their notes so as not to upset patients, and important pieces of information may be lost as a result.

"I believe that a good doctor-patient relationship should be based on honesty regarding diagnosis and treatment options," Dr. Salamon said. "However, the medical record and notes are a place where doctors should be able to describe uncertainties, subtle observations, and speculations while an evaluation is being undertaken without having to worry about needlessly upsetting patients who may not have the medical background to interpret the process."

So what do you think? Would you like to see your doctor's notes? For what purpose? Is there a danger that they will be misinterpreted?

This post by PeterWehrwein of Harvard Health Publications appeared at Get Better Health, a network of popular health bloggers brought together by Val Jones, MD. Better Health's mission is to support and promote health care professional bloggers, provide insightful and trustworthy health commentary, and help to inform health policy makers about the provider point of view on health care reform, science, research and patient care.