You and the physicians you work with may be at least a tad skeptical about sharing clinical notes with patients as federally mandated under the new information-blocking rules that took effect in April.
But the practice was first introduced in the 1970s and as of 2020, more than 50 million patients in the United States and Canada had access to their visit notes. Studies that began in 2010 show that patients appreciate the window into what their doctors are thinking and value seeing themselves reflected in the note.
An AMA STEPS Forward™️ open-access toolkit, “Sharing Clinical Notes with Patients,” will help you understand the evidence that supports sharing visit notes with patients, identify how to educate team members on the new federal mandate for open notes, and learn how to write notes that are better suited for patients’ eyes. The toolkit also will help physicians, patients and caregivers make the most of openly shared clinical notes.
“Though it may seem a daunting change at first, the transition to open notes ends up being relatively seamless for most individual clinicians as well as organizations, especially with proper preparedness,” the toolkit says.
The toolkit outlines six steps to help your practice successfully share open notes. The first step involves educating your team about the benefits of open notes.
Research shows that patients who read their notes say they:
- Feel more in control of and engaged in their health care.
- Recall their care plan more accurately.
- Are better prepared for visits.
- Have a better understanding of their medical conditions and medications.
- Are more likely to adhere to their medications.
- Are able to identify clinically important errors in their notes.
- Are not more worried or offended after reading their notes.
- Have more successful conversations and stronger relationships with their doctors.
And the research shows that physicians and other clinicians who share their notes reported:
- Improvements in patient satisfaction, safety, communication and education.
- Improvements in the patient-physician relationship, including enhanced trust, transparency, communication and shared decision-making.
- Patients who are better prepared for their clinic visits and are becoming more actively involved in their own care.
- No increase in time needed to address patient questions about their notes.
- Willingness among physicians to recommend to colleagues the use of open notes.
There are five more steps—outlined below—to help implement a good system, the AMA toolkit says.
Look at various policy considerations for your practice or organization. For example, how will important errors that patients find be corrected? How will proxies access patient notes? How will notes that deal with sensitive topics, such as mental health and obstetrics, be handled?
Communicate with patients in multiple ways. For example, send patients an email introducing open notes. Make patient-specific FAQs available in all waiting rooms, exam rooms, on the patient portal and anywhere else patients can easily access them.
Dramatic changes aren’t needed. But those who have used open notes acknowledge eliminating language that could be perceived as critical of the patient. That includes removing expressions such as “noncompliant,” “patient denies” and “patient refuses.”
The best approach is often to discuss with the patient everything you are putting in the visit notes, using the same words that will appear in the notes. Be direct and respectful.
Collect information on the use of and perspectives about open notes through informal hallway conversations, at team meetings and by adding questions about it to patient satisfaction surveys. You also can track patient emails and phone calls about it.
Another helpful CME module, “Information Blocking Regulations: What to know and how to comply,” is accessible through the AMA Ed Hub™ online learning platform. It builds on two essential information-blocking resources made available by the AMA last year.