Physician Support for Open Notes Grows Over Time, With Caveats

Marcia Frellick

April 29, 2021

Although most physicians surveyed expressed doubt about sharing clinical notes with patients before having done so, a new longitudinal study finds that their outlook has shifted dramatically with experience.

The findings, which come just weeks after federal legislation began requiring physicians to share notes with patients, were published online on April 22 in the Journal of General Internal Medicine.

James Ralston, MD, MPH, and his team at Kaiser Permanente Washington Health Research Institute, in Seattle, Washington, analyzed responses from 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.

Before implementation, 29% of physicians agreed or somewhat agreed that making notes on clinical visits available online benefited patients overall. After implemnation, that percentage grew to 71% (P < .001). In addition, 44% of physicians switched from thinking it was a bad idea to thinking it was a good idea. Only 2% switched from thinking it was a good idea to thinking it was a bad idea (P < .001).

Attitudes shifted after implementation across all clinician categories.

"I think the overall message is positive: It's likely going to have less impact on your practice than you think," Ralston told Medscape Medical News.

Number Who Worried About Time Demands Drops

The proportion of physicians concerned that office visit time would increase dropped from 47% before implementation to 15% after. The percentage of those who thought more time would be needed for patient questions dropped from 71% to 16%. Similarly, before implementation, 57% thought it would take more time to produce the notes; after implementation, 28% thought so.

Beliefs that patients would have more control of their care were strong to start with and increased slightly, from 72% to 78%. By contrast, beliefs that patients would worry more if they could see the notes decreased slightly, from 72% to 65%.

Both before and after implementation, most clinicians said note sharing led to their notes being less candid (65% vs 52%).

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

Shifting Landscape

Ralston and colleagues note that responses of patients have been consistently positive. For example, patients report being better prepared for clinic visits, having better understanding of their care plan, particularly medications, and feeling more in control of their care.

But few studies have assessed physicians' views over time, and there is still considerable work to be done to make open notes valuable and effective.

In some areas, confidence in note sharing dropped significantly.

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

"To realize its potential to improve safety, quality, and experience of care, open notes may need to be coupled with additional interventions," the authors write.

Mental Health Clinicians 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 notes.

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

"Mental health clinicians have more to be concerned about ― not only the motivation of patients looking at their notes but also what they're apt to conclude from them," he said.

Reidbord, who blogs for Psychology Today, told Medscape Medical News he doesn't think that note sharing is bad and that patient engagement is always good. "I just don't think it helps anything. It's a feel-good measure," he said.

Reading clinical notes isn't the best way to engage patients in their care, he said. He pointed out that clinical notes are often technical and typically are filled with jargon.

More helpful, he said, would be more patient-directed literature to help patients ― "not the work product of the doctors who are trying to get the work done."

He continued, "Transparency is good. It’s just that this is a poor tool to do that."

Open notes likely are best suited to primary care, he said. He agrees that it's good to know from this study that most physicians were reassured that open notes do not increase their workload or visit time.

When asked about the drop in physicians' belief that open notes would improve patient safety or satisfaction over the study period, Ralston said the likely explanation is that the number of patients who read notes was smaller than they had expected.

"We had 10% to 11% of our notes being read," he said. "We waited until we had 11 continuous months where 10.5% of the notes were being read, and that occurred only after we started sending patients an email notification that they had a note ready for review."

That may undermine one of the purposes of open notes, in that if patients aren't reading the notes, they won't be pointing out errors and asking questions that might improve safety and quality.

Reidbord said that if patients aren't reading the notes, it fuels the question of the value of open notes.

Additionally, 74% of physicians surveyed reported that the value of their notes to other clinicians remained the same before and after implementation, "with a quarter (25%) reporting much less or somewhat less value," the authors say.

"It's one more thing doctors have to do that doesn't really help healthcare," Reidbord said. "The notes aren't for public consumption, particularly. You don't go to a restaurant and ask the chef to see their recipes. It's not a secret, it's just not part of the experience."

The survey was funded by The Group Health, Robert Wood Johnson, Gordon and Betty Moore and Cambia Health Foundations. The authors and Reidbord have disclosed no relevant financial relationships.

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

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

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