The idea of sharing the physician note with patients instinctively felt reckless. And yet, in 2017, SBH had begun to explore the possibility of using the Follow My Health Portal for patients to get access to their progress notes. Pat Belair, SBH’s senior vice president of Ambulatory Services and Strategy, was the first to propose the idea. She saw the possibility from the patients’ perspective – a project that could enhance the patient experience and impact patient safety.
But as I heard the proposal, my reaction was less than enthusiastic, even pessimistic. After all, my thinking went, the clinic note wasn’t meant for patients. It was a document intended to communicate clinical assessment and plans to other providers using technical medical terms, while fulfilling ever expanding regulatory and billing mandates. The note’s utility and readability, especially in the age of EMR, was raising questions even among clinicians. It seemed improbable that patients could use the note. But as I researched the topic, I was faced with growing evidence that patients also benefited from access to the note. Equipped with the latest research and best practices, the burgeoning patient safety movement known as “Open Notes” was looking for clinical partners to share notes with patients. And with SBH’s chief medical officer Dr. Eric Appelbaum’s agreement and encouragement, the decision was made to join the movement and analyze and report back its findings. My initial hesitation, however, wasn’t born just out of my own bias. A look at the development of the SOAP note (an acronym for subjective, objective, assessment, and plan) reveals the initial goals of medical documentation were focused on provider needs and not patient centered. Instead, the note served to standardize and refine the clinician’s thinking while also innovating in the field of medical education. Although the patient stood to benefit from the improvement of this standardization, the note wasn’t developed for the patient’s consumption.
Of course, the SOAP note was pioneered during another era in medicine. It was in the late 1960’s when Lawrence Weed, the dean of healthcare information technology, first introduced the problem-oriented medical record. American healthcare, in the intervening time, has transformed several times over. Today, the term “patient” can be substituted with “consumer.” The term “change” goes beyond mere semantics and signals the changing role of the patient in medical decision-making while hastening the endof paternalism. Furthering this trend, the publication of “To Err is Human,” the Institute of Medicine’s seminal work on medical errors, forced the healthcare industry into necessary introspection. The patient’s central role in their care could no longer be minimized. With digitization of health records that paved the way for patient portals, patients were now equipped with tools that could bolster their new central status. Put together, these trends advanced the notion that the physician note could be a resource for patients to further their care.
In the fall of 2017, SBH joined a collaborative of New York hospital systems to learn more about Open Notes and lessons learned on implementation. The first forum set out to address questions from each of the participating organizations. Wouldn’t patients be confused by the note with its complex medical terminology? What about non- English speakers? There were concerns about liability and possible malpractice implications. But the most pressing issue was how this would impact clinician workflow in an already challenging documentation environment. After all, the more time spent with an EMR meant less time for patients.
For the workflow concerns, a study surveying PCPs who had implemented Open Notes showed very few changes to the practice of medicine. In a one-year analysis on Open Notes, 140 PCPs from three geographically distinct regions were surveyed about the impact to the practice; few doctors reported longer visits (0 to 5 percent) or more time addressing patients’ questions outside of visits (0 to 8 percent). Three to 36 percent of doctors reported changing documentation content; and 0 to 21 percent reported taking more time writing notes. To further this point, the authors of the study reported some PCP’s questioned whether the project went live, noting that they saw no impact to the practice.
While the PCP experience was minimal, patients seemed to gain significant benefit. In the largest Open Notes study, 5,000 patients in three separate hospital systems were surveyed about the impact of reading the doctor’s note. In it, 85 percent of patients said Open Notes helped them feel more in control of their care. A remarkable 60 to 78 percent of those taking medications reported increased medication adherence. Only a minority of patients, from 1 to 8 percent, reported that the notes caused confusion, worry, or offense. The data demonstrated that benefits far outweighed the harm.
In another survey, 99 percent of patients valued access to notes. The top reasons listed included: remembering next steps, quicker access to results, greater confidence in clinicians, and the ability to share with care partners.
Based on this data, and a commitment to improving the patient experience, SBH will be one of the first New York sites to participate as an Open Notes healthcare system. Part of this project will be soliciting clinical input to guide implementation. A survey for physicians will establish baseline attitudes regarding the sharing of notes and perceived concerns. In addition, physician champions will represent each department and serve as sounding boards for the project. The following champions have agreed to lead the effort: Gerard Baltazar, D.O., George Manis, M.D., and Thomas Rechtschaffen, M.D., from the Department of Surgery; Tina Chee, M.D., from the Department of Medicine; Paula Amendola, D.O., from Family Practice; and Lisette Robledo, M.D., from Pediatrics. Working to gain the patient’s perspective on Open Notes will be Caroline Davis, Director of Patient Engagement and Community Outreach. Lastly, the IT department, led by Dr. Jitendra Barmecha, M.D., will provide the technical expertise and project management to facilitate all teams working together to meet the project’s goals.