Patient communication

How physicians feel about open notes access

Two recent studies on physician attitudes about open notes are particularly relevant now that federal rules require health care professionals to provide them.

A study on ophthalmologists’ opinions on open notes, published recently in Nature, found that many think their patients will have trouble understanding their medical records and may be unnecessarily distressed and/or offended by them. The survey of 29 clinicians at the University of Colorado’s ophthalmology department also found that some were worried that open notes requirements would increase their workload and force them to change the way they document.

The same clinicians also listed benefits to open notes, including improving patient understanding of their conditions, strengthening patient–physician trust, and enhancing patient care.

Due to a program rule for implementation of the 21st Century Cures Act, health care professionals have been required to give patients access to all health information in their medical records without delay since April 2021.

One caveat to the Nature study is that the survey was conducted before open notes were implemented at the University of Colorado, meaning it provides a snapshot of concerns and perceptions among physicians who were not yet working with open notes. Also, the study noted that ophthalmology notes are unique in that they heavily use drawings and non-standardized abbreviations; they are often incomprehensible to other clinicians, let alone patients.

“This study suggests that ophthalmology clinicians may have fears and concerns regarding the implementation of OpenNotes that differ significantly from those of other clinicians,” the study authors wrote. “As such, health systems implementing OpenNotes should recognize the unique challenges that note-sharing poses in ophthalmology, educate ophthalmology providers on the benefits of note-sharing, and collaborate with these providers to work toward the goal of making notes more comprehensible to patients.”

Physician attitudes before and after open notes implementation

Another recent study of physician attitudes about open notes provided survey data from 192 physicians across multiple specialties from before and after open notes were implemented at their institution. Published in the Journal of General Internal Medicine, the study revealed that prior to implementation, only 29% of the physicians thought open notes were a good idea. Roughly 44% of the physicians went from thinking open notes were a bad idea to believing they were ultimately beneficial.

The study suggests that physician concerns about the negative impacts of open notes on their day-to-day practice of medicine were significantly reduced after open notes were implemented. However, a number of physicians remained worried after implementation.

Physicians’ open notes concerns before and after implementation
Open notes concern Percentage of physicians pre-implementation Percentage of physicians post-implementation
Office visits taking longer 47% 15%
More time needed for questions 71% 16%
Producing notes will be more onerous 57% 28%

Interestingly, more physicians also reported being less candid in their notes following implementation, and they also were more likely to think patients with open notes access would worry more about their treatment or conditions.

“Compared to before implementation, substantially fewer clinicians thought open notes increased patient safety and satisfaction,” the study authors wrote. “Perception of improved satisfaction dropped over one-half, from 40% to 17%, and perception of safer care dropped from 33% to 11%. These changes further reflect the less-than-anticipated impact of open notes on practice. To realize its potential to improve safety, quality, and experience of care, open notes may need to be coupled with additional interventions.”

Related content:

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2 comments

  1. Having dealt with “open charts” for over 2 years, the main problem I and my group has found is that abnormal results drop to the patient through the required patient portal before we can even review and address the results. Typically we will address the results in a timely fashion and the patients are ultimately satisfied with their “safe and appropriate” care.
    That being said, surprise, surprise, something that our betters in the federal government imposes on us leads to more unneeded work and stress on physicians that are “burning out” at an unfortunate and unsustainable rate.
    “The most terrifying words in the English language are: I’m from the government and I’m here to help.”
    -Ronald Reagan

  2. The shift to open notes and open access is one of those things where problems don’t come up as often as we were fearing, but when they do, they’re just as bad as you’d expect. Some stands-outs in my mind:

    1) A patient did not realize that some sexual history that they were giving would be documented, and panicked. Their concerns were less about medical staff knowing those details and more about the idea that other family would need to care for them in the distant future; would gain access to this trove of notes; and would then read it. I didn’t think their family would want to read through digital stacks upon stacks of records, but they thought otherwise: an issue that wouldn’t exist without open notes. This not only took up more time from the original encounter, but likely led to their being more guarded and careful about what information they revealed, knowing it would be in the record.

    2) A patient who could not be reached by phone read the note documenting these efforts and, seeing that it was in a note, became upset and hostile (citing the note specifically). I would guess that if there were no note access, they would have called the clinic, instead.

    3) A patient who found out their diagnosis of cancer by looking in their record, before a clinician could contact them. They were upset to have found out this way.

    I have more to share, but I’m reaching the character limit. Even if these are less frequent than expected, what has been GAINED from all this access?

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