The Views and Experiences of Clinicians Sharing Medical Record Notes With Patients

DesRoches, Catherine M.; Leveille, Suzanne G.; Bell, Sigall K.; Dong, Zhiyong; Elmore, Joann G.; Fernández, Leonor; Harcourt, Kendall; Fitzgerald, Patricia; Payne, Thomas H.; Stametz, Rebecca; Delbanco, Thomas L.; Walker, Jan

doi:10.1001/jamanetworkopen.2020.1753

Cited by 90 publications

(85 citation statements)

References 25 publications

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“…A major focus of current survey research is the influence of open notes on physicians' documentation practices. In multiple surveys, as a result of patient access to their notes, many clinicians report being more mindful of the words that they use (6,11). For example, in a recent large-scale survey, the majority of primary care physicians describe adjusting their language to avoid being perceived as critical of patients with around half omitting terms such as "non-compliant, " and "patient denies, " or modifying how they document sensitive clinical, mental or social information (6).…”

Section: Survey Evidence Of Documentation Changesmentioning

confidence: 99%

“…In multiple surveys, as a result of patient access to their notes, many clinicians report being more mindful of the words that they use (6,11). For example, in a recent large-scale survey, the majority of primary care physicians describe adjusting their language to avoid being perceived as critical of patients with around half omitting terms such as "non-compliant, " and "patient denies, " or modifying how they document sensitive clinical, mental or social information (6). In addition, around a quarter (26%, n = 61) of U.S. primary care physicians report employing more partnering or encouraging language in their notes (6).…”

Section: Survey Evidence Of Documentation Changesmentioning

confidence: 99%

“…For example, in survey research in Sweden, one in five (22%, n = 147) mental health clinicians [(12), p. 2], and two in three (67%, n = 43) oncologists (15) admitted writing less candid notes. In the U.S., the majority (69%, n = 108) of mental health clinicians report writing fewer details (11), and a quarter (26%, n = 63) of primary care physicians report changing how they document differential diagnoses (6). In a major survey of US physicians from different medical specialities, 22% (n = 168) did consider their notes less valuable (6) because of open notes.…”

Section: Survey Evidence Of Documentation Changesmentioning

confidence: 99%

See 2 more Smart Citations

Does Patient Access to Clinical Notes Change Documentation?

Blease

Torous

Hägglund

2020

Front. Public Health

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Section: Survey Evidence Of Documentation Changesmentioning

confidence: 99%

Section: Survey Evidence Of Documentation Changesmentioning

confidence: 99%

Section: Survey Evidence Of Documentation Changesmentioning

confidence: 99%

See 1 more Smart Citation

Does Patient Access to Clinical Notes Change Documentation?

Blease

Torous

Hägglund

2020

Front. Public Health

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“…Twenty-three percent said they changed the way to document differential diagnosis. 27 This concern about documenting sensitive information was and continues to be, a particular issue for notes prepared by mental health specialists.…”

Section: Patient and Clini Cian E Xperien Ce S With Open Note Smentioning

confidence: 99%

Healthcare in the new age of transparency

DesRoches

2020

Seminars in Dialysis

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Similar to other areas of society, debates around access to and ownership of an individual's digital information have taken center stage in health care. A decade ago, the idea of offering patients ready access to their clinical notes was a fringe idea. Today, information transparency in health care has become a pressing legislative and regulatory issue in the United States and elsewhere. 1 The 21st Century Cures Act of 2016 requires that clinicians and health care organizations give patients electronic access to the information in their electronic medical records. Rules to enact this legislative priority promulgated by the Office of the National Coordinator for Health Information Technology and the Centers for Medicare and Medicaid have substantially expanded the types of information that must be easily accessible to patients and readily exchanged among clinicians in electronic form. 2 These regulations around information blocking, which take effect on November 2, 2020, require health care organizations and clinicians to share the following eight note types: consultation, discharge summary, history & physical, imaging, laboratory, and pathology report narratives, procedure notes, and progress notes. 3 By 2022, patients will be able to access this information in their records through any third party app of their choosing. The hope is that this increased transparency will improve care and the delivery system for patients, families, and clinicians; that it will positively impact patient safety; and that it will contribute to health care value for all stakeholders. Patients receiving dialysis are at particular risk for fragmented care, given the complexity of their needs and the number of clinical sites and providers involved in their treatment. 4 While the Centers for Medicare and Medicaid Services has incentivized coordination across dialysis stakeholders, it did does specifically target greater health information exchange between providers. 5 The current lack of interoperability between disparate EHRs prompted calls for increased investment in improved data exchange specifically for dialysis patients, similar to the work supported by CMS through the Promoting Interoperability programs in place for hospitals

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“…These findings echo the positive experiences of non-oncology clinicians, now replicated in several large-scale surveys. 8 Before implementing open notes, many oncology physicians worried that the notes would become less detailed, thereby reducing their usefulness. However, several analyses indicated no evidence exists of objective changes—eg, word length, number of words per sentence, or the positive or negative emotional tone—to oncology documentation after patient access was permitted.…”

mentioning

confidence: 99%