Open Notes for All — Tips and Techniques for Writing Compliant, Meaningful Open Notes
By Elizabeth S. Goar
For The Record
Vol. 33 No. 5 P. 24
There is plenty to be praised about open clinical notes, with studies showing a range of patient-centric benefits, including enhanced patient empowerment and improved medication adherence. But many clinicians continue to view open notes with trepidation—a feeling that has intensified for some in the wake of the 21st Century Cures Act mandate requiring open patient access to clinical notes as part of its information blocking prohibition.
Specifically, effective April 5, the Cures Act requires health care providers to give patients free access to all the health information in their EMRs “without delay” or risk being reported for information blocking and fined up to $1 million per occurrence. The mandate covers eight types of clinical notes: consultation, discharge summary, procedure and progress notes, history and physical, and imaging, laboratory report, and pathology report narratives.
“Open notes go back almost 10 years, and what we learned in the early years is that people were very worried that things were going to need to be done differently, or that patients would respond in challenging ways. But, really, none of that ever came to pass,” says Steven Lane, MD, MPH, FAAFP, FAMIA, a primary care physician and Sutter Health’s clinical informatics director for privacy, information security, and interoperability. “Clearly, there are some providers who have an opportunity to make their notes more patient-friendly, both more understandable and more appropriately or compassionately worded with the thought that the patient is more likely now to read them.”
Pros and Cons
The concept of open clinical notes is not new. Ambulatory physicians in Sutter Health’s network have been sharing their notes with patients for years, and all ambulatory clinicians from Sutter Valley have been live on the OpenNotes system since 2016. According to the organization, most participating clinicians report very minimal or no impact from the practice and overall feedback has been positive.
The same holds true nationally. According to the OpenNotes organization, which has been studying the effects of open and transparent communication on patients, care partners, and clinicians for more than a decade and has helped more than 260 organizations transition to practicing in an OpenNotes environment, more than 50 million patients were able to access their clinical notes by the end of 2020.
According to a study in the May 2021 issue of the Journal of General Internal Medicine, 50% of clinicians trying OpenNotes for the first time ultimately determined that their patients took better care of themselves when given access and about 75% reported greater patient empowerment.
An earlier study in the Annals of Internal Medicine found that OpenNotes enhanced medication adherence for 14% of patients and helped 64% of patients better understand why a specific drug was prescribed. OpenNotes helped 62% of patients feel more in control of their medications, while 57% said they were able to find answers to questions they had about their medications in their notes.
But positive experiences and rapid adoption do not necessarily mean that adopting an OpenNotes platform is a piece of cake. Association for Healthcare Documentation Integrity President-Elect Stacy Lehto, CHDS, AHDI-F, says that accuracy is paramount, noting that focusing on patient friendliness at the expense of accuracy and completeness could spell trouble.
“Providers need to be held accountable for documentation that accurately captures the patient’s story not only for the patient to be able to read and understand but also for other health care providers to base treatment on,” says Lehto, who is also the senior health care documentation quality analyst for Spectrum Health’s Business Service Center. “Basing treatment on erroneous information charts the course for patient safety concerns and potential risk to patient care.
“Ultimately, the ability for patients to access their medical records is a blessing and a curse,” she continues. “The best provider, the best facility in the world will lose all credibility when documentation is done poorly and riddled with inaccurate or inconsistent information.”
Accuracy is a very real concern—one that patient access to clinical notes may actually impact. According to information posted by OpenNotes, when patients review their notes, they become an extra set of eyes on the information and occasionally find issues that require correcting.
According to the OpenNotes organization, studies have found that nearly 10% of patients find errors in their records, and they view one-quarter of these as serious. Twenty-five percent of physicians who have been offering open notes for more than a year report that patients have found errors that the clinician felt were serious.
Another area of concern is documenting open notes that are meaningful to patients while still successfully capturing the information coders and clinical documentation improvement specialists need to perform their jobs. Ideally, physicians will organize the content they want to include in the note, taking care to include only that which is pertinent to avoid burying or losing the critical components of the documentation.
Lehto notes that ensuring the note is consistent, concise, and accurate is a primary consideration when documenting open notes. Has the provider been sensitive to the reader of the document, understanding what they put in the note is read by the patient?
“The provider needs to try to avoid acronyms that may not be well known outside the medical industry, so they need to remember their audience. They also need to be sure they appropriately recapped the patient’s story,” Lehto says, adding that coding queries that result in additional information that completes a patient’s story can also be problematic. “As far as I’m aware, queries are not typically seen by the patient, which is why the practice of physicians responding to the queries themselves but not amending the documents can be so dangerous. Any time something is added or changed in a patient’s record, it should be written so that it is okay for anyone to see.”
Making It Work
To stay compliant when documenting open notes, Lehto suggests creating templates and/or SmartText that prompts for the required information. Also, physicians and anyone else who contributes to the medical record should be current on all facility and regulatory documentation requirements.
Lane advocates against the use of abbreviations and acronyms “and basically any words that a patient or your mother wouldn’t be able to understand.”
Given health care’s affinity for using acronyms, he admits that is not easy. “People have made jokes about it, but, for example, when you call shortness of breath ‘SOB,’ someone may think you’re calling them a son of a bitch and that’s not a good thing. So avoid acronyms.
“Also, some of the terminology that we use that some people might find either sensitive or offensive. Calling somebody who is obese ‘obese’ [in the note] can be a challenge if you haven't actually had a discussion about that as part of the care that you're providing them. Or describing somebody as disheveled. There are often kinder words that providers could use to tell just as complete a story.”
In some cases, Lane says, the issues are generational. Older physicians tend to be more resistant to documenting for patient consumption. But age isn’t the only culprit. Deeply entrenched habits also come into play.
“We get in the habit of using certain terminology with some abandon in medical notes” that aren’t the most patient-friendly way to document care, Lane says. “Everybody takes words and their meanings a little bit differently and there could easily be some hurt patient feelings if they feel judged,” he says.
At the same time, physicians should be working with their patients to educate them on how and why to access their clinical notes. Lane ends each encounter by telling patients that they can read everything he’s written in their chart and inviting them to reach out with any questions or concerns about what they see.
“It’s really as simple as that,” he says, admitting that “the providers who are less enthusiastic about having patients read their notes are probably less likely to do that.”
However, Lane says it falls on the clinician and the organization to take the time to educate patients on the importance of accessing their clinical notes, particularly given the benefits that have already been realized from doing so—for example, improved patient satisfaction, as well as better patient compliance, engagement, and understanding of their care.
Patients who read their notes are also more likely to be prepared for upcoming visits, benefiting both patient and clinician. Which is why OpenNotes encourages a practice it calls OurNotes, in which physicians invite their patients to contribute to the record by writing a concise, structured interval history and proposing a visit agenda. Doing so may offload work during a visit and free up time that proves mutually beneficial.
Lane notes that there will always be situations in which writing OpenNotes will be awkward or difficult.
“There will always be some people who will have a negative experience with this,” he says, but access to clinical notes actually does “raise the bar for clinicians to make sure that they’re doing a really careful job, both taking care of you and documenting that care. For those clinicians who are up to that task and take it seriously, this yields a net benefit.”
Lane continues: “It really is a marker for those clinical cases or situations where you need to put more effort into your communications, be it your oral or your written communications, to make sure that patients are engaged, educated, and understand what is going on. If you can't do that, you just need to keep at it. Keep trying to make the message clear, because there are plenty of situations in clinical care where that is needed.”
— Elizabeth S. Goar is a freelance writer based in Wisconsin.