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In April, the federal government mandated that healthcare providers provide free electronic access to patients' clinical notes, as part of the 21st Century Cures Act. This includes eight types of notes spanning outpatient and inpatient arenas. If providers/organizations do not comply with this mandate, they will be subject to fines due to "information blocking."
This was born out of the "Open Notes" movement -- which declares itself to promote and study transparent communication in healthcare by sharing notes with clinicians and patients. The hypothesis is that with increased patient access to notes, quality and safety of care will improve.
The Open Notes movement suggests that patients reading their own notes will "add a second set of eyes." But is that the way we want to shape healthcare? How did we get to a point where patients are now the targeted audience of clinical notes?
The first signs of a modern medical record started in the early 19th century in Paris and Berlin. These written records involved recording disease states and remedies primarily for advancing the treatments in medicine. It became clear to practitioners that keeping a record improved medical advances as well as patient outcomes. At this point, the record was kept by and for clinicians for the purpose of providing improved care.
Fast forward to the late 20th century, and the delivery of healthcare changed. With the creation of Medicare and Medicaid came a dramatic increase in healthcare spending. Various regulatory departments (utilization, coding, quality, etc.) were thus created to address these rising costs. The medical note, which was now shifting to become electronic, was a targeted way to track these changes.
For example, utilization is a department that is born out of rising medical costs, a department tasked with looking at how healthcare "utilizes" services. Providers would need to document the justification of why a patient needed a certain test like an MRI instead of an x-ray, a medication when others were available, a hospital stay instead of an outpatient visit, etc.
These new requirements of documentation caused the medical note to shift once more -- now kept by physicians not only to provide care but also to track the effectiveness, utility, and quality-of-care provided.
Now we are shifting the purpose and audience of the medical note even further. Notes have already become an increasing point of contention and cause of burnout for physicians. Less time is spent with patients, and more and more is spent next to a computer.
If patients now have open access to all notes, how will this change the content and purpose of the medical note even further?
I have watched my organization send out information about how to comply with this new policy. Providers have been educated on this change and told that it should not change the workflow or content of a note.
But is that realistic? I had a patient come in for weight loss recently, and I considered cancer as a differential. But I found myself hesitant to write this in a note that my already anxious patient could immediately see. I considered that this could be due to a thyroid condition rather than malignancy, but I was trained to consider every possible differential. The differential and the medical note is a large portion of the art of practicing medicine. There is immense value in it. This point was ingrained in me throughout my medical training.
If Open Notes does in fact lead to a change in the way physicians document, what could be the downstream effects? The quality of care may suffer.
Some providers may choose not to include information they feel the patient may perceive in a negative light. This may be to preserve the doctor-patient relationship or to avoid negative patient satisfaction -- which doctors are already tracked on.
Some may be hesitant to include information they normally include to convey to other treating providers -- for example, a patient with suspected drug-seeking tendencies or family members suspected of secondary gain. Within Open Notes regulations, exceptions are noted for psychiatric notes, and notes that the physician believes are likely to cause harm to the patient.
What constitutes harm, though, seems unclear, and if providers do not comply with this rule, they will be subject to fines due to "information blocking."
Ultimately, if we devalue the documentation aspect of patient care, then patient care will suffer. While I understand the need for healthcare transparency and the possible benefits of increased coordination and healthcare literacy, I can't help feel that the pitfalls have not been properly addressed.
With each change in healthcare, it is difficult to truly anticipate the downstream effects it causes to the industry. Time and time again, we have put forth further regulations from outside bodies to "improve care" that have led to anything but.
And now in a predictable fashion, healthcare providers must comply with further regulations dictating the way in which they provide care -- and who can be surprised?
Sneha Tella, MD, is an internal medicine physician.
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