Notes in the electronic health record (EHR) have long been promoted as a way to keep patients involved in their care and to cut down on inquiries about what’s in the record. A new study shows that this promise is being kept.
Patient files have long been something seen only by clinicians and others involved in care. However, the advent of the electronic health record (EHR) and the 21st Century Cures Act in 2016, which stated patients should be given access to all the information in their file including notes written by the clinician, changed how patients could access their personal health information. A new study in JAMA Network Open looked at how this change impacted practice.1
The investigators used a web-based survey to ask about clinical note sharing with physicians, advanced practice nurses, registered nurses, physician assistants, and therapists who were part of 3 health systems in rural Pennsylvania; Boston, Massachusetts; and Seattle, Washington. Notes had been shared with patients in all outpatient specialties for at least 4 years. Clinicians included in the study had written at least 1 note that had been opened by a patient in the year before the survey was given in the summer of 2018.
From a potential pool of 6064 clinicians, 1628 responded. Those who responded were more likely than nonrespondents to be female and younger by an average of roughly 2 years. The majority were physicians, women, had been licensed to practice in 2000 or later, and had spent fewer than 40 hours in direct patient care. Seventy-four percent said that they had a positive opinion of notes and believed they were a good idea. Among the 1314 clinicians who knew that patients were reading the notes, 74% said that open notes were a good way to engage patients. Overall, 61% of the respondents said they would recommend using notes to their colleagues.
Some change is necessary
Utilizing the note functionality did require some changes. A number of clinicians said they changed how they wrote their notes, with 422 saying that the biggest change was linked to language usage, in particular language that could be seen as critical of the patient. More time spent on documentation was reported by 292 respondents. The vast majority said that they liked having the ability to easily see if the notes had been read by their patients.
Ready access to notes in the record was seen as a positive step to keeping patients engaged in their care. With the COVID-19 pandemic and the push to do more appointments via telemedicine, notes can help keep doctor and patient on the same track and give families pertinent information without needing to contact the practice.
1. DesRoches CM, Leveille S, Bell SK, et al. The views and experiences of clinicians sharing medical record notes with patients. JAMA Netw Open. 2020;3(3):e201753. doi: 10.1001/jamanetworkopen.2020.1753