I (Dustin) shadowed a doctor with a well-established practice when I was a medical student on a family medicine rotation. He was the type of physician we associate with a bygone era in medicine, when the doctor-patient interaction began by catching up on what was going on with kids and the like.
This doctor loved talking to his patients, and he did something I hadn't seen before (or since): He would end the encounter by dictating his note with the patient listening. He would nod to reinforce certain points like, “We stressed increased activity for weight control.” He would occasionally stop to check his accuracy, saying something like, “That has been three weeks on the new blood pressure medication, right?” He would turn over his tape recorders for dictation by his staff. I thought about this doctor's approach to clinical communication as our hospital system rolled out its OpenNotes functionality.
OpenNotes, which are physician notes available and transparent to the patient, twists convention. (https://www.opennotes.org.) OpenNotes cofounder Tom Delbanco, MD, an internal medicine physician at Harvard Medical School/Beth Israel Deaconess Medical Center, was inspired decades ago while talking with a patient. “And I was writing notes, but I said to myself, this guy is a printer, he can probably read upside-down what I'm writing about him right now,” Dr. Delbanco said in an interview. “So, I said to him, ‘Mr. A., you know, I'm stuck, because I think you can see what I'm writing, right?’ And he said ‘Yes.’ And I said, ‘So the problem is that your case is a classic one of early alcohol abuse, but I don't want to write that down if it's not true.’ And he paused, and then said, ‘Well, you'd better write it down.’” (Healthcare Innovation. Oct. 3, 2016; https://bit.ly/3zp3H8d.)
Patient Epiphany
This story was told to us not long ago by OpenNotes scholar Charlotte Blease, PhD, who said this was an epiphany for the patient who was able to address and recover his health and his life. It was also “transformational” for Dr. Delbanco who parlayed the moment into a movement.
Dr. Blease came to Harvard in 2017 as a Fulbright Scholar, and was working in a division of the hospital that was trialing OpenNotes. The concept resonated with what she understood about the ethical underpinnings of clinical communications. The recognition that patients could be “diagnostic collaborators” was liberating to their autonomy but also potentially at odds with the professional autonomy of the physician. The larger question seemed to be whether the decision to implement OpenNotes would be an error of commission or omission. Was there more risk in doing it or not doing it?
Our hospital system has been using OpenNotes since last fall. Many of our ED colleagues were skeptical during the training. We were told to try not to use words like unreliable or poorly compliant, not to use abbreviations, and to avoid medical jargon. We balked at these instructions because they were counterintuitive to our long-established practice. Like other EPs, our notes have always been written for three audiences: physicians who would interact with the patient and wanted to have an unfiltered account of previous encounters, lawyers who could subpoena the notes if there were malpractice litigation, and billing coders who would figure out how much to charge for the encounters.
Dr. Blease discussed these concerns with us. “The truth is that many people are going to Google their illness regardless, and if they have the specifics from their doctor's note, they will be better able to use technology to get more accurate information,” she said, adding that patients are the most underutilized resource in medicine. “They have the most at stake and are most able to pick up inaccuracies and provide context.”
Increase Trust
Some worry about the balance of medicolegal documentation and risk in the OpenNotes era, but sharing notes can increase trust and perhaps mitigate litigiousness. “A sense of control and understanding can go a long way,” Dr. Blease said. There is no doubt that improved communication can strengthen the patient-provider alliance; survey-based evidence supports the argument that OpenNotes can enhance such communication. (Pract Radiat Oncol. 2019;9[2]:102; JAMA Netw Open. 2020;3[3]:e201753; https://bit.ly/3iHEwYS; OpenNotes. https://www.opennotes.org/research.)
Despite initial skepticism, we are coming around to the notion of OpenNotes as a step in the right direction. And just in time. Federal regulation implementing the 21st Century Cures Act requires physician notes, with a few exceptions, to be available to patients as of April 5. (The Office of the National Coordinator for Health Information Technology. https://bit.ly/3xovWlB.)
Clearly challenges still exist, especially in the ED. OpenNotes may not be appropriate and could be detrimental in certain situations (e.g., patients who doctor shop for prescription drugs or acted in a threatening manner toward the doctor or staff), and must continue to serve multiple other functions (inform other physicians and provide medicolegal protection). OpenNotes exceptions are not yet finely tuned to ED dynamics like this. Changing an Epic note template to spell out SOB is simple enough to make for patient understanding (and satisfaction), and it worries us that colleagues have reported that they changed the nature of their notes, making them less detailed and more nuanced about patient behavior.
Maybe that old-school family physician wasn't so old school after all. We suspect he would have shared his dictations with his patients if he had a quick and easy way to do so. But he surely would have recognized that today's physician note serves many masters and is an imperfect tool to capture the physician-patient experience and a poor substitute for a clear and permanent record of the most important moments of a clinical encounter.
OpenNotes is just a start. Today, we have the technology to capture the most critical and patient-centric pieces of a discussion and preserve those for patients and families. This technology might be as simple as a voice memo on a smartphone, but it could soon be smarter and more automated than that. (JAMA. 2017;318[6]:513; https://bit.ly/3xmaBtm.) Like it or not, we are in a new era of transparency, and EPs can advocate for solutions that empower the patient and physician.
Dr. Vinsonis an emergency physician at Kaiser Permanente Sacramento Medical Center, a chair of the KP CREST (Clinical Research on Emergency Services and Treatment) Network, and an adjunct investigator at the Kaiser Permanente Division of Research (https://www.kpcrest.net/). Dr. Ballardis an emergency physician at San Rafael Kaiser, a past chair of the KP CREST Network, and the medical director for Marin County Emergency Medical Services. Read their past articles athttp://bit.ly/EMN-MedClear.
