Read what your doctor said about you
OpenNotes allows patients to view comments made on medical records
Requests for medical records occur daily in health care, with UPMC printing out and shipping more than 10,000 sets of records in the average month.
But what if you can’t recall how your doctor described a recent diagnosis or bloodtest result? What if you were so stressed out that you can’t remember key details from your appointment?
As it turns out, 22 million people already have easy access to doctor’s notes in their electronic medical records with OpenNotes, a philanthropic organization co-founded by Harvard Medical School and Beth Israel DeaconessMedical Center, leading the campaign tomake such information readily available.
The law is clear: People have the right to access their full medical records.
Through the OpenNotes process, patients simply log into their health system’s patient portal, click a tab and read what their doctor typed into their medical record during or after an appointment or treatment — the medical language, acronyms and occasional typos included.
This summer, UPMC plans to launch OpenNotes on its MyUPMC patient portal to allow its patients to see exactly what their doctor said about them after an appointment or treatment procedure.
“Generally patients have to formally request their medical records from medical centers or hospitals,” said Glenn Updike, medical director of the MyUPMC patient portal, which already provides access to test results, medications and other health information. “It is giving the option of reviewing your medical records in the comfort of your home with caregivers, among other benefits for patients.”
OpenNotes’ mission statement says, “Ready access to notes can empower patients, families and caregivers to feel more in control of their health care decisions and improve the quality and safety of care.”
According to OpenNotes, patients and physicians alike benefit, with few challenges for hospitals, health systems and doctors in opening the portal for patients.
But be aware there could be some misinterpretations when doctors use medical acronyms. For example, your record might say, “Albuterol for the SOB,” which isn’t a comment on the patient’s personality but an acronym for “shortness of breath.” HA is a headache rather than an exclamation. And MVP is no award but rather a mitro valve prolapse.
Overall, OpenNotes represents a push toward transparency in health care prices, quality and patient information.
“We started eight years ago with a small pilot project with 105 clinicians, 20,000 patients and a very radical idea,” said Cait DesRoches, OpenNotes medical director. “Now we have 22 million people” with full online access to doctors’ notes. “We are in the middle of a movement figuring out who owns our information, and hospital records are part of that — ‘This is my information so you need to give it to me.’ “
Most patients, she said, generally understand what they read or can figure out the medicallanguage with help from the internet.
“Anyone — even the most educated patient — remembers about 50 percent of what they hearin a clinical visit,” Dr. DesRoches said. “If the appointment is particularly stressful, including a poor diagnosis, the percentage of informationremembered decreases.
“So OpenNotes serves as a way to extend the visit, go back and refresh your memory. Patients say it allows more control over their health,” she said. “They better remember their care plan and do a better job in taking their medications and sharing notes with otherpeople such as a daughter or a spouse.”
Doctors quickly discover they need to make few, if any, changes in composing their notes. Even if it does take a bit longer, they likely will receive fewer follow-up calls from patients, she said.
Robert Bart, UPMC chief medical information officer, said the provider can decide to prevent patient access to behavioral or