Study Examining the Effect of Patients Reading Their Doctor’s Notes
The notes a doctor takes during a visit with a patient can be crucial to that person’s care and overall level of treatment. These notes can help a doctor review a patient’s medical condition, form a diagnosis and share information with others who may participate in that person’s care. For some time, the question has been whether patients should, or would even want to, review what their physicians write in those notes.
The movement for patients and consumers to review their own medical records began in the 1970s. During that time, states began enacting laws that promoted open access for medical records and patients’ rights. In 1996, the Health Insurance Portability and Accountability Act (HIPAA) was passed by Congress and signed into law by President Clinton. This legislation codified a patient’s right to view medical records, including notes made by a doctor, and request amendments to them.
Despite actions on the state and federal levels, patients making an effort to review their own medical records and notes has long been the exception and not the rule. Many critics have pointed to bureaucratic obstacles that provide less incentive for patients to make these requests, such as copying costs and the length of time it takes for some providers to respond.
A new study, called the OpenNotes Project, is studying the effect of patients reviewing their doctor’s notes. Three hospitals and over 100 primary care physicians will be participating in the project. Over 25,000 patients will be eligible to participate in the project. Throughout a 12 month period, patients will be able to log on to a secure portal to view their medical records and notes from their physician. According to The New York Times, the main question researchers want answered is whether patients want to continue to view their records at the conclusion of the study.
Opponents of open access fear that patients may misread or misunderstand doctor’s notes and that there are better ways to communicate this information to patients. They also fear that when doctors suspect a more serious diagnosis, such as cancer or heart disease, patients may have unnecessary worries about the direction of their care.
There is also the risk of misunderstanding medical shorthand for some terms. For example, doctors will often abbreviate shortness of breath as “SOB” and an abnormal sound or movement on the chest wall as a “thrill.”
Improved Communication Key to Better Health Care
Advocates, however, say that the more communication patients have with their doctors, the better. Studies have shown that when patients have improved communication with their doctor, the result is better health care.
The Annals of Internal Medicine notes previous research that seems to support the idea of transparency between a doctor and patient. In prior studies conducted on a smaller scale, patients were allowed access through secure websites to review their own records and notes. Patients who participated in those studies felt more empowered, more educated about their own health care and were more willing to correct serious errors or omissions made by their doctors.