The OpenNotes era has ushered in the possibilities of greater patient and family collaboration in shared decision-making and reduced barriers to documentation sharing. However, it has raised new ethical and clinician documentation considerations. In addition to clinician education, patients and families could benefit from education around the purpose of clinical documentation, how to utilize OpenNotes, and the benefits of engaging in dialogue regarding the content and tone of documentation.
Peer Reviewed
Open notes sounds great, but will a provider’s documentation change? An exploratory study of the effect of open notes on oncology documentation
This study evaluated whether implementing open notes at a large academic medical center was associated with changes in measures of the length and readability of progress notes written by hematology/oncology clinicians. After the implementation of open notes, progress notes and A&P sections became both longer and easier to read. This suggests clinician documenters may be responding to the perceived pressures of a transparent medical records environment.
A natural language processing pipeline to synthesize patient-generated notes toward improving remote care and chronic disease management: a cystic fibrosis case study
Our study demonstrated that an NLP pipeline can be used to create an automated analysis and reporting mechanism for unstructured PGHD. Further studies are suggested with real-world data to assess pipeline performance and further implications.
Physician Use of Stigmatizing Language in Patient Medical Records
This qualitative study found that physicians express negative and positive attitudes toward patients when documenting in the medical record. Although often not explicit, this language could potentially transmit bias and affect the quality of care that patients subsequently receive. These findings suggest that increased physician awareness when writing and reading medical records is needed to prevent the perpetuation of negative bias in medical care.
Knowledge, power, and patients: The ethics of open notes
But do patients really need access to their health information, or should electronic health records be the sole preserve of physicians? We explore this question using our own case studies.
Changes in Clinician attitudes toward Sharing visit Notes: Surveys Pre-and Post-Implementation
Following implementation, more primary and specialty care clinicians agreed that sharing notes with patients online was beneficial overall. Fewer had concerns about more time needed for office visits or documentation. Most thought patients would worry more and reported being less candid in documentation.
Association of Patients Reading Clinical Notes With Perception of Medication Adherence Among Persons With Serious Mental Illness
Surveys show that clinicians worry that patients with mental health diagnoses will become anxious, confused, or upset after reading their visit notes. In this study, we examined how patients with a mental illness diagnosis who read at least 1 clinical note in the last 12 months perceived how reading the note affected their adherence to prescribed medication.
Open Anesthesia Records: Guidance for Anesthesia Providers on Implementing the Cures Act
Open anesthetic records may empower patients. Armed with previous anesthetic records, patients may be better prepared to communicate prior adverse events or side effects. We may also see more patients who seek the same “cocktail” of anesthetics that were provided to them in the past or may ask for the same anesthesia providers who have cared for them. Overall, patients should be able to better communicate their satisfaction or dissatisfaction with prior anesthetic experiences. Anesthesia providers will also have access to a wealth of important information, like airway management details, from prior out-of-network anesthetic records.
The Value of OpenNotes for Pediatric Patients, Their Families and Impact on the Patient–Physician Relationship
Although limited by relatively low survey response rate, OpenNotes was well-received by parents of pediatric patients without untoward consequences. The main concerns pediatricians raise about OpenNotes proved to not be issues in the pediatric population. Our results demonstrate clear benefits to adoption of OpenNotes. This provides reassurance that the transition to sharing notes with pediatric patients can be successful and value additive.
Words Matter: What Do Patients Find Judgmental or Offensive in Outpatient Notes?
One in 10 respondents reported feeling judged/offended by something they read in an outpatient note due to the perception that it contained errors, surprises, labeling, or evidence of disrespect. The content and tone may be particularly important to patients in poor health. Enhanced clinician awareness of the patient perspective may promote an improved medical lexicon, reduce the transmission of bias to other clinicians, and reinforce healing relationships.
