Patients can now see doctor’s notes
Many people trying to gather their health-care data may be all too familiar with calling medical records departments, driving to a clinic to sign a release, and paying a fee for a pile of papers with loads of medical information they don’t understand.
But this spring, new federal rules went into effect that will allow patients to see the clinic notes physicians write, which advocates say will improve patients’ knowledge of their own health.
Supporters of the open notes effort say they are optimistic that this change will make a big difference because people will be able to click on their patient portal — such as MyChart and other similar apps — and see what their doctors have written, rather than just a list of often confusing test results and other information. Psychotherapy counseling notes are except from the new requirements.
Catherine DesRoches, executive director of OpenNotes, a think tank that promotes sharing clinical notes with patients, calls this a “new world” where shared notes are valuable tools to improve communication between patient and physician while strengthening their relationship.
But not all doctors are as enthusiastic, concerned that patients might misinterpret what they see in their doctors’ notes, including complex descriptions of clinical assessments and decisions.
Suzanne Salamon, associate chief of clinical geriatrics at Beth Israel Deaconess Medical Center in Boston, says giving patients more info is good, but she worries about how using common doctor terminology might come across: “words like ‘drug seeking behavior’; patients wanting oxycodone and I felt that it wasn’t necessary, you have to be careful about how you say that, because the patient may feel it was necessary and may really resent the fact that you’re thinking that they’re a drug-seeking person.”
The medical note has gone through many evolutions since the first known medical note in 1800 B.C. Egypt, when surgical cases were transcribed onto papyrus and used for teaching at a later time. In the 18th century, clinicians wrote private journal entries. In the 20th century, notes became integrated into medical records, in an effort to systematize the collection of health information and data for billing.
The electronic format introduced in the 1980s — and now used in most U.S. medical practices and hospitals — offered an arguably more efficient way to store and share medical data for use, primarily, by medical staff. Now, the medical note written by doctors after they have seen a patient is being morphed into a tool to communicate with the patient rather than just among health-care providers and billing departments.
DesRoches says she thinks this new format will “help even out the power imbalance between patients and clinicians.” Or, as the OpenNotes website puts it, it is “motivated by evidence indicating that when health professionals offer patients and families ready access to clinical notes, the quality and safety of care improves.”
“Your health record is your health record,” says Bettina Experton, a public health physician in California.
“It’s your physician’s record as well. But you have a right to access it,” adds Experton, founder of a clinician led tech company that has been advocating for over 20 years to give patients easier access to their health information, including clinic notes.
Stan Brady, a 65-year-old patient at the Cleveland Clinic with multiple chronic illnesses, says that reading the clinic notes from his primary care and orthopedic physicians has helped clarify the physician instructions and remind him of medication regimens.
When DesRoches first heard of shared notes, she thought this was going to be useful for only patients who were highly educated and well resourced. But after years of research, her group observed that patients who are traditionally underserved by the health-care system are more likely to report benefits from reading their notes.