Risks and rewards of increasing patient access to medical records in clinical ophthalmology using OpenNotes

Abstract

Background The implementation of OpenNotes and corresponding increase in patient access to medical records requires thorough assessment of the risks and benefits of note-sharing. Ophthalmology notes are unique among medical records in that they extensively utilize non-standardized abbreviations and drawings; they are often indecipherable even to highly-educated clinicians outside of ophthalmology. No studies to date have assessed ophthalmologist perceptions of OpenNotes. Methods A cross-sectional study was conducted from 4/28 to 5/12/2016. A survey was distributed to 30 clinicians (25 ophthalmologists, three optometrists, two nurses) in the University of Colorado’s Department of Ophthalmology to evaluate provider attitudes towards granting patients access to online medical records. Results Many clinicians felt patients would have difficulty understanding their records and may be unnecessarily alarmed or offended by them. Some clinicians worried their workload would increase and feared having to change the way they document. Perceived benefits of OpenNotes included improving patient understanding of their medical conditions, strengthening patient–physician trust, and enhancing patient care. Many perceived risks and benefits of note-sharing were associated with conceptions of the ideal clinician–patient relationship. Conclusions Clinicians in ophthalmology perceived both benefits and consequences of increasing patient access to ophthalmic records, and there were significant correlations between these perceptions and their conceptions of the clinician–patient relationship. This is the first study to assess potential ophthalmology provider attitudes toward sharing ophthalmic records. Although limited in sample size and power, this study demonstrates some ways patient-accessible ophthalmic records can affect the clinical practice of ophthalmology and emphasizes the unique challenges of OpenNotes in ophthalmology.

Applications of natural language processing in ophthalmology: present and future

“…With the advent of the Open Notes movement, a movement supporting transparent documentation among patients, families, and clinicians ( 116 – 118 ), and the 21st Century Cures Act of 2021 ( 119 ), which mandated patient accessibility to their clinical notes, there has been an increasing emphasis on patient involvement and advocacy in their own care. However, previous work in ophthalmology exploring clinician attitudes toward Open Notes revealed concerns that patients would have a difficult time understanding their records ( 120 ). In fact, the terminology used in ophthalmology notes have been anecdotally difficult to understand even among clinicians in other specialties, reflected by the creation of tools used by non-ophthalmologists to help “translate” ophthalmology notes by replacing common abbreviations used in ophthalmology ( 121 ).…”