Your Note: Your Patient Is Now Reading Your Note: Opportunities, Problems, and Prospects Jared W. Klein, MD, MPH Sara L. Jackson, MD, MPH Sigall K. Bell, MD Jan Walker, RN, MBA Tom Delbanco, MD Joann G. Elmore, MD, MPH Show al

Your Patient Is Now Reading Your Note: Opportunities, Problems, and Prospects From Researchers at U of Washington and Harvard Med School

Caduceus at the town hall of Neumünster (Germany) by Uwe Barghaan, Wikipedia; Neumünster - Schleswig-Holstein (Germany), Mosaic at the town hall,

Jared W. Klein, MD, MPH Sara L. Jackson, MD, MPH Sigall K. Bell, MD Jan Walker, RN, MBA Tom Delbanco, MD Joann G. Elmore, MD, MPH Show al (Editor's Note: Researchers at the Univ. of Washington and Harvard Medical School)

Patients have unprecedented online access to their medical records. More than 6 million Americans can now read their doctors' notes via patient portals, and continued rapid growth is likely.

Sharing notes with patients may yield important health benefits, including increased patient empowerment and improved medication adherence.

Seeing written information, including notes, helps patients remember the plan of care, reinforces patients' positive behaviors, and strengthens the patient–doctor alliance.

As fully transparent medical records proliferate, many questions remain unanswered (Table 1). Such uncertainties create anxiety and apprehension among doctors at a time when many already feel overwhelmed. In an effort to ease the transition to what we believe will be a widespread and ultimately beneficial practice, we draw on over 5 years of the authors' clinical experience and conversations with clinicians around the country to offer suggestions for creating notes that can work for all concerned (Table 2).

Table 1: Outstanding Questions About Open Notes

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Should the content and format of notes be changed?
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Can the patient's “story” return to the medical record and if so, how, and to what degree?
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Which patients may benefit from reading notes, and which may not?
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Should some notes be hidden, and how can that be explained to patients?
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Will patients withhold important information if they sense that transparency poses threats to their privacy?
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Will they uncover errors that could diminish trust and even fuel litigation?

Table 2Suggestions for Implementing Open Notes in Clinical Practice

Suggestion

Examples

Be clear and succinct

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When possible, enlarge the font size or use boldface text to emphasize important items such as “Check your blood sugar twice a day.”
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Consider beginning your note with the Assessment and Plan section.
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Do not import multiple pages of data available elsewhere in the chart; instead, include only pertinent aspects of the current visit.
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Avoid jargon. Use electronic tools to convert abbreviations to the full spelling. Use dictation or spell checking software to review note content.
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Caution patients about misspellings and word substitutions or include templated statements explaining the potential sources of typographical errors.
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Consider using second person instead of third person voice. For example, “Start taking lisinopril and check your blood pressure twice a week,” rather than, “Initiated lisinopril and instructed to check her blood pressure twice a week.” More direct language may help reinforce instructions for patients.
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Insert links to reliable online resources for educational information and clarification of acronyms or medical terms.

Directly and respectfully address concerns

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Obese patients. Review their body mass index and the definitions for overweight, obese, and morbidly obese with patients so that they understand why these terms are in the chart.
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Possible cancer. “You have some symptoms concerning for colon cancer (blood in stool, weight loss, family history of early colon cancer), so I will facilitate an expedited referral to the gastroenterologist. If it is colon cancer, we want to catch it early when there are more treatment options.”
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Drug use. “Cocaine use is causing your extremely elevated blood pressure and difficulty with relationships.”
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Mental health. “Increased feelings of worthlessness and thoughts of self-harm. No active suicide plan and willing to seek care if thoughts worsen. Your grandchildren remind you of reasons to live. Check in tomorrow with your counselor and don't forget the crisis line number.”
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If documentation could cause harm to the patient (for example, intimate partner violence if access to the patient portal is obtained by abuser), discuss this with the patient in advance. Consult with a social worker or legal counsel and consider blocking this note from the patient portal.
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Remember that, with rare exceptions, HIPAA protects patients' right to view records. Shielding notes from an online patient portal does not prevent patients from submitting a written request for their records.

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