Patient Access to Doctors' Notes May Improve Care

Joe Barber Jr., PhD

October 01, 2012

October 1, 2012 — Primary care physicians and patients believe that allowing patients to review doctors' notes has significant benefits and few problems, according to the findings of a quasi-experimental trial.

Tom Delbanco, MD, and Jan Walker, RN, MBA, both from Beth Israel Deaconess Medical Center (BIDMC) in Boston, Massachusetts, and colleagues published their findings in the October 2 issue of Annals of Internal Medicine.

The authors remarked that providing patients access to medical records and doctors' notes could have both advantages and disadvantages. "Electronic medical records and secure patient portals hold exciting potential for more active patient involvement in care and improved communication between patients and clinicians," they write. "These technologies facilitate a potentially disruptive innovation: Doctors can readily invite patients to read and share their visit notes and even contribute to the notes' formulation."

In this study, the authors recruited doctors and patients from 3 hospitals (BIMDC in Massachusetts, Geisinger Health System [GHS] in Pennsylvania, and Harborview Medical Center [HMC] in Washington). A total of 105 primary care physicians and 13,564 of their patients participated in the study. Among the 5391 patients across the 3 institutions who opened at least 1 note and completed a postintervention survey, 77% to 87% reported that open notes allowed them to feel more in control of their medical care and 60% to 78% of those taking medications reported improved medication adherence.

The authors included primary care physicians who desired to participate and excluded housestaff, fellows, and physicians at BIDMC community practices that lacked portal-compatible records. Names of the participating doctors were posted on the Web site and the researchers invited all patients at BIDMC and GHS who used portals, unless specifically excluded by their primary care physicians. They individually invited patients at HMC except for those with a history of major mental illness, substance abuse, or both.

No Extra Time Required

Among the doctors who participated in the postintervention survey, no more than 5% reported longer patient visits, and 0% to 8% of doctors at the 3 institutions reported spending more time answering patients' questions outside of visits. In total, 99% of patients who completed the postintervention surveys wanted open notes to continue, and no participating physician declined to continue using open notes at the end of the 12-month intervention period.

However, the views of patients and physicians did differ regarding the actual content of the notes. Between 59% and 62% of patients believed that they should be able to add information to the notes, compared with 17% to 39% of physicians. Moreover, approximately 33% of patients believed that they should be able to approve the doctors' notes, whereas 85% to 96% of doctors disagreed.

The limitations of the study included the inclusion of only 3 medical centers, all of which had electronic medical records and patient portals; the inclusion of limited numbers of each doctor's patients, including patients already familiar with use of portals; poor patient survey response rate of only 41%; and potential confirmation bias among the respondents.

The authors note that their findings support the use of open notes among patients. "In response to a relatively simple intervention, the patients in this large-scale trial reported striking benefits and presented a clear mandate to continue open notes," the authors write. "Despite important limitations in our study and the need for much more exploration, our findings suggest that expanding such transparency is the right thing to do."

In a related commentary, Michael Meltsner, AB, JD, from the Northeastern University School of Law in Boston, reported that his own experience with illness confirmed the importance of transparency between physicians and patients. "In the middle of the journey, I suddenly acquired a serious medical condition and, ironically, a strong personal interest in finding out what my doctors thought was the source and nature of my illness, the available options, my precise response to treatment, and what I could do to increase my chances of survival," Meltsner writes. "Having experienced openness from the doctors I frankly did not fully expect, I am both confirmed in my views about the value of transparency and grateful that we have moved beyond the many grim days my family suffered from its absence."

The study and the authors were funded by The Robert Wood Johnson Foundation, the Drane Family Fund, the Richard and Florence Koplow Charitable Foundation, and the National Cancer Institute. Mr. Meltsner has disclosed no relevant financial relationships.

Ann Intern Med. 2012;157:461-470.

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