Mind the Gap

Mind the Gap

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It’s a simple idea – show patients the notes that doctors write about them– but it’s also a dangerous idea … in the best sense of the word. It’s dangerous because the very idea forces a conversation and in the course of that conversation, some uncomfortable tensions surface. Jan Walker and Tom Delbanco, co-directors of OpenNotes, a project supported by the Robert Wood Johnson Foundation’s Pioneer Portfolio that enables patients to see their doctors’ notes via secure e-mail after a visit, published a preliminary set of results from their first study. Actually, it’s just a pre-study: they surveyed doctors and patients about their expectations of how the OpenNotes idea would play out. And what they found is fascinating – and uncomfortable.

Doctors and patients are clearly divided about the expected benefits and consequences of the OpenNotes intervention. On a wide range of possible benefits, ranging from a greater sense of control to increased medication adherence, doctors are more skeptical than patients. But what really jumps out are the responses to questions of whether patients would find the notes more confusing than useful, and whether the notes would make them worry more. The gap is dramatic. In each case, most doctors said “yes” while less than one in six patients agreed. Ouch. That’s a big gap and my sense is that we should be talking about what it means. From my perspective, it appears that many doctors are underestimating their patients and that this underestimation could lead to less patient engagement and ultimately poorer care. Call it a hunch.

To be fair, doctors are a varied lot and the paper shows clearly that doctors who chose not to participate in the study are far more skeptical than those who did participate. But even those who did were still way off from their patients on questions of confusion and worry.

As I mentioned, these are only the expectations and the year ahead should bring plenty more to discuss. The results from the one-year demonstration of OpenNotes should be available for publication in the spring.

What do you think of these initial results? What do you make of the gap? And how do we start to close it?

Stephen J. Downs is the Senior Technology and Information Officer, Robert Wood Johnson Foundation.

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22 Comments on "Mind the Gap"


Guest
MD as HELL
Dec 23, 2011

The content of notes will change. I don;t think too many patients want to read they are “massively and morbidly obese”. I alos am qiute certain that doctors will have to devote a lot of time over disputed content in said notes. Nothing good will emerge from this.

Guest
Dec 23, 2011

I recently read a note about myself that contained the results of many assessment tests that were not done. Maybe having the patients read the notes will make them more accurate.

I also remember reading the notes after having my 5th child at age 36. I was amused to see I was an elderly grand multip. Writing that about someone else is one thing. Reading it about myself just made me laugh.

Guest
Dec 23, 2011

I don’t see a problem with this. That’s what patient portals are supposed to be for, ultimately. Yes, the notes will change and yes there may be disputes over “charting by exception” content, which could have ramifications to coding.

But here are my questions: are people that receive notes in better health? are outcomes translatable into better care? are costs of care lower?

Guest
southern doc
Dec 23, 2011

My guess is no, no, and no.

This innovation will be expensive and time-consuming to gratify the wishes of the entitled few.

I’m more concerned about my patients who have no computer, no job, no transportation, and no insurance. What are we going to do for them?

Guest
Dr. Mike
Dec 27, 2011

You would have to change the payment system in order to effectively share notes with patients. We are paid based upon what we write about what we did, not on what we did, so notes have become almost useless as means of conveying a meaningful summary of what transpired at the patient/doctor encounter. EHRs have only made this worse. The patients guess that our notes contain a useful summary of the visit or encounter, the docs know that they are full of fluff and sometimes meaningless medical speak because that is the only way in which we can be compensated for their services, and because we must document in a way that protects ourselves in the event of a lawsuit.

Guest
Dr. Mike
Dec 27, 2011

Try and imagine having all your conversations and activities documented by another party, and that the other party assumes that you are potentially going to sue them someday. How would that change what they document about what was or wasn’t said in each conversation or what was or wasn’t done in each activity? You should try it yourself – after the fact, document a conversation or activity, and assume that the other person will sue you. See if you can write a note that doesn’t cast your words and actions in the best possible light. Now imaging the other person reading the notes, and imagine if they could possibly disagree with your description of what transpired.

Guest
Lisa
Dec 28, 2011

I want the doc and patient to discuss the notes before the visit is completed. I’ve seen incorrect info much later, and seen a diagnosis years later that I was never told about. Recently the doc pushed an otoscope so far in my ear I reflectively yelled. I asked that the event be put in my chart. I was told it was. I had to call back (unrelated issue) and wanted to confirm it was added to my chart. It was not. I had to go back to the clinic and demand it be included. The doc blew me off and walked out of the front office At that point, I had to demand a copy of my patient records and I wouldn’t leave until I had the doc’s verbal acceptance (in front of the office staff) that this event would be recorded. I received the records, with her “sanitized” version of the event.

This situation blew out of control because she didn’t want anything in my record that she could later be sued for, and as a result, I was lied to and blown off. She was eventually reprimanded, but I never would have known had I not tried to confirm the records were correct.

I now ask every doctor before I leave the appointment exactly what was written in my records. It’s sad I have to do this, but as Dr. Mike says, the records aren’t for our information, although the records should support our needs as well as the doc’s (except the need to spin the visit to avoid lawsuits).

Will reviewing the notes together take more time? Can a doc write and speak at the same time? Personally, I don’t care if it takes a little longer if it forces a conversation and confirms the outcome of the visit.

Guest
MD as HELL
Dec 28, 2011

Keep your own record. The quality of the encounter should not be affected by the record. If it is, then one of you had a hidden agenda and were not honest in the encounter.

Guest
southern doc
Jan 1, 2012

“Recently the doc pushed an otoscope so far in my ear I reflectively yelled. I asked that the event be put in my chart.”

Why?

Guest
Lisa
Jan 1, 2012

southern doc … I was there simply to get a prescription refill for something unrelated. She was doing the routine screen – “take BP, listen to your heart, look in your nose and ears.” My ears were fine – no infection or anything.

Guest
southern doc
Jan 1, 2012

Again, why did your yell need to be a part of your permanent medical record?

Guest
Lisa
Jan 1, 2012

As this event was something that occurred during my visit and negatively impacted my health, I asked that the event be put in my record.

Guest
southern doc
Jan 2, 2012

A sharp pain in your ear was an event that negatively impacted your health?

Sorry, we’re not talking the same language.

Guest
Lisa
Jan 2, 2012

Southern doc … I think I was pretty clear about my thoughts regarding notes made during visits. Going into any more detail isn’t really relevant to that original point. Regards.

Guest
southern doc
Jan 2, 2012

The doc’s note is a analytical synthesis of the most important aspects of the history, exam, and decision making process during and after the office visit.

If you expect a documentary record of everything that occurs during that visit, it is up to you to create your own record, or to audiotape or videotape the visit.

Sorry, but your expectations of what should be in the medical record are unrealistic.

Regards.

Guest
Lisa
Jan 2, 2012

I understand that I have not given you enough information to fully understand the situation, so your conclusions are based on a subset of the history/decision making, etc., that occurred. I’m sorry I won’t explain this in gory detail to give you the big picture – that wasn’t the point.

This went on a tangent about what you thought I meant by “event” – I’ll just refer back to my original comment regarding discrepancies in the record contents and what I was told or not told. Perhaps originally I should have just mentioned the first two examples – incorrect information and the unrevealed diagnosis (both of which had been important for me to know) – and not relayed a third example – that I had been lied to about what was in the record.

The issue of discrepancies was my focus, and it appears that message was clouded. I don’t think it’s unrealistic that my records be correct, that I should be allowed to confirm them, and that I should be told all test results.

Guest
southern doc
Jan 3, 2012

Thanks for the clarification. I understand your concerns now.

Guest
southern doc
Jan 3, 2012

Addendum: as we move to EMRs, with the expectation that the note be completed during the office visit in order to maintain productivity, inaccuracies and discrepancies will become more common, and will be spread throughout your entire record, becoming more difficult to correct and remove.