{"id":935,"date":"2014-08-03T15:02:54","date_gmt":"2014-08-03T22:02:54","guid":{"rendered":"http:\/\/blog.stevenreidbordmd.com\/?p=935"},"modified":"2014-08-03T15:22:31","modified_gmt":"2014-08-03T22:22:31","slug":"opennotes-good-intentions-gone-awry","status":"publish","type":"post","link":"http:\/\/blog.stevenreidbordmd.com\/?p=935","title":{"rendered":"OpenNotes: Good intentions gone awry"},"content":{"rendered":"

\"opennotes_logo\"<\/a>OpenNotes<\/a>\u00a0is “a\u00a0<\/span>national initiative\u00a0working to give patients access to the visit notes written by their doctors, nurses, or other clinicians.” \u00a0According to their website, three million patients now have such access, generally online. \u00a0Participating institutions include the\u00a0MD Anderson Cancer Center in Texas, Beth Israel\u00a0Deaconess in Boston,\u00a0Penn State Hershey Medical Group,\u00a0Kaiser Permanente Northwest, and several\u00a0others. \u00a0Patients with a premium account in the My HealtheVet<\/a> program at the VA have access to outpatient primary care and specialty visit notes, discharge summaries, and emergency department visit notes. \u00a0The New York Times<\/em>\u00a0recently ran a mostly celebratory\u00a0piece on OpenNotes as applied to mental health visits at BI Deaconess (“What the Therapist Thinks About You<\/a>“), garnering over 350 public comments. \u00a0Significantly, many of these comments expressed\u00a0annoyance\u00a0with any mental health professional who cited potential drawbacks\u00a0\u2014\u00a0despite the fact that BI Deaconess doctors who actively participate in OpenNotes concede\u00a0that such openness may be detrimental for those with “psychiatric or behavioral issues”\u00a0(e.g., see this promotional video<\/a>, starting at 2:15).<\/span><\/p>\n

The notion\u00a0of sharing clinical notes with patients enjoys\u00a0populist appeal. \u00a0On a self-report\u00a0survey<\/a>\u00a0with no control or comparison condition, patients reported that OpenNotes helped them remember what was discussed during visits, feel more in control of their care, and improved their medication adherence. \u00a0Advocates also say\u00a0it improves communication with patients\u00a0and\u00a0can correct factual errors in the record. \u00a0However, the strongest argument seems to be that patients like it. \u00a0Defenders\u00a0repeatedly invoke\u00a0“transparency,”\u00a0implying that\u00a0the status quo is intentionally obscure\u00a0and aims to hide something from patients. \u00a0Some of the rhetoric has a defiant, even self-righteous tone: one promotional video<\/a>\u00a0(at 3:16) features a patient who pointedly declares that she’ll never be refused this access again. \u00a0And there’s no clear endpoint:\u00a0about 60%\u00a0of\u00a0the\u00a0patients surveyed\u00a0in the OpenNotes study believed they should be able to add comments to a doctor’s note, and about a third\u00a0believed they should be able to approve the notes’ contents; the overwhelming majority of participating\u00a0physicians disagreed with the latter. \u00a0If OpenNotes is widely accepted, it will be increasingly difficult to draw clear lines regarding the authorship and authority of clinical notes.<\/p>\n

Fifty-five percent\u00a0of eligible primary care doctors\u00a0declined to participate in the OpenNotes study cited above. \u00a0Of those who did participate:<\/p>\n

Several doctors struggled with the notion of a one-size-fits-all note, arguing that one\u00a0document cannot address the needs of billing, other doctors,\u00a0and<\/em>\u00a0patients. \u00a0A few changed their own use of the note; for example, eliminating personal reminders about sensitive patient issues, excluding alternate diagnoses to consider for the next visit, restricting note content, or avoiding communication with colleagues through the note…. A substantial minority reported [changing documentation, in particular when addressing potentially sensitive issues],\u00a0including their reported change in \u201ccandor.\u201d For example, some doctors reported using \u201cbody mass index\u201d in place of \u201cobesity,\u201d fearing that patients would find the latter pejorative.<\/p><\/blockquote>\n

\u00a7 \u00a0\u00a7 \u00a0\u00a7<\/p>\n

“Progress note,” not “visit note,” is the traditional term\u00a0for a physician’s written entry into a patient’s medical record, documenting an outpatient or inpatient encounter. \u00a0(OpenNotes advocates may find “progress note” too\u00a0quaintly\u00a0optimistic to be publicly acceptable.) \u00a0Physicians write other notes for other purposes, including admission notes, procedure notes, transfer notes, discharge notes, and so forth. \u00a0Additionally,\u00a0many\u00a0notes are written by nurses and a wide variety of\u00a0other clinical personnel, particularly in inpatient settings.<\/p>\n

The traditional\u00a0format\u00a0of a progress note\u00a0documents\u00a0(1) symptoms and (2) physical examination,\u00a0including lab test results, obtained by the physician, (3) his or her differential diagnosis, and (4) the\u00a0next steps, such as\u00a0further exams, tests, or treatments, that follow therefrom. \u00a0Medical students are taught to write SOAP notes<\/a> as an acronym for these four components. \u00a0Such notes assist in performing and archiving\u00a0medical\u00a0work, much as a scientist’s laboratory notebook records the design, data, and results of experiments. \u00a0Progress notes were not<\/em> designed to be\u00a0a legal defense against malpractice suits, justification for third-party payment, quality-assurance tools for health institutions, or educational handouts\u00a0for\u00a0patients.\u00a0\u00a0Yet\u00a0these notes now serve many masters, resulting in excessively time-consuming documentation that squeezes out face-time with patients, and\u00a0is\u00a0increasingly cumbersome<\/a>\u00a0as a clinical tool. \u00a0\u00a0Some of the additional trade-offs in adding yet another stakeholder, the patient reviewer, are cited in the quotation above, and\u00a0cannot be casually dismissed as balderdash<\/a> by defenders of OpenNotes.<\/p>\n

OpenNotes presumably\u00a0works best in primary care, and with an electronic medical record that expands abbreviations (and\/or provides templates), corrects spelling, and produces legible output that patients can access online. \u00a0In contrast,\u00a0notes with technical jargon by specialists such as ophthalmologists, anesthesiologists, radiation oncologists, and many others\u00a0would be incomprehensible unless radically altered to be more patient-friendly. \u00a0Less “connected” practices would similarly be left out. \u00a0But even in the\u00a0best-case scenario, progress notes are a poor tool for doctor-patient collaboration. \u00a0By nature they are shorthand, telegraphing complex medical reasoning in a few words. \u00a0Old-fashioned discussion is paradoxically superior for assuring that\u00a0doctors and patients are\u00a0“on the same page.” Written material designed specifically for patients is better suited for reminders about what was discussed and how to take medications as prescribed.<\/p>\n

The real thrust of the OpenNotes initiative is less pragmatic. \u00a0Many patients want to feel more in control of their care. \u00a0In addition, doctors aren’t trusted as profoundly as we used to be. \u00a0If given\u00a0the chance, many patients will gladly join the ranks of\u00a0those who look over our shoulder. \u00a0And of course, if the traditional use of progress notes is framed as paternalistic or elitist, reforming these notes into something “democratic” seems like the only sensible thing to do. \u00a0The enthusiastic fervor\u00a0to empower patients in this misdirected way (further) dulls a useful documentation tool which is no more inherently elitist or paternalistic than the work notes of a car mechanic or the recipe notes of a chef. \u00a0Everyone feels good about this newfound “transparency.” \u00a0And\u00a0that, apparently, is what really counts.<\/p>\n

These considerations apply doubly in the case of mental health notes. \u00a0My colleague who writes the Psych Practice blog\u00a0wrote a response<\/a> to the New York Times<\/em> piece on sharing therapy notes. \u00a0I agree with her completely. \u00a0I’d only underscore that psychotherapy based on psychoanalytic and psychodynamic principles\u00a0depends crucially on gauged disclosure and the timing of verbal interventions. \u00a0These treatments\u00a0anticipate and rely on the reality that the perspectives of therapists and patients inevitably differ, and that this discrepancy is not a\u00a0simple\u00a0error or miscommunication, but instead is the engine that drives\u00a0psychological change. \u00a0Arguing\u00a0for transparency in such treatment is tantamount to wishing that these therapies disappear (some critics will readily acknowledge this).<\/p>\n

The relationship between doctors and patients should always be collaborative, but it is never equal. \u00a0One party is ill and needs help, the other offers expertise and resources the other doesn’t have. \u00a0“Giving everyone a say” sounds democratic, but medicine isn’t practiced\u00a0democratically. \u00a0Try asking a\u00a0car mechanic or a\u00a0chef at a fine restaurant (or your child’s schoolteacher, or an architect, or a police officer…) if you can share in their work-flow and decision making. \u00a0Most will initially appreciate your interest and offer\u00a0you an overview. \u00a0A kind one may let you look under the hood. \u00a0However, very soon you will be told that you are in the way\u00a0\u2014\u00a0that you can watch intently or enjoy a good result, but not both. \u00a0There is nothing paternalistic about this, it’s how\u00a0skilled workers do\u00a0their jobs. \u00a0When reminded that this applies to physicians as well, and once the thrill of the “forbidden” behind-the-scenes look wanes, we will see that the remaining advantages of OpenNotes are better served by other means.<\/p>\n","protected":false},"excerpt":{"rendered":"

OpenNotes is “a national initiative working to give patients access to the visit notes written by their doctors, nurses, or other clinicians.” According to their website, three million patients now have such access, generally online. Participating institutions include the MD Anderson Cancer Center in Texas, Beth Israel Deaconess in Boston, Penn State Hershey Medical Group, […]<\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_monsterinsights_skip_tracking":false,"_monsterinsights_sitenote_active":false,"_monsterinsights_sitenote_note":"","_monsterinsights_sitenote_category":0,"footnotes":""},"categories":[4,51],"tags":[20],"class_list":["post-935","post","type-post","status-publish","format-standard","hentry","category-current-events","category-psychiatry-in-general","tag-therapist-disclosure","odd"],"aioseo_notices":[],"_links":{"self":[{"href":"http:\/\/blog.stevenreidbordmd.com\/index.php?rest_route=\/wp\/v2\/posts\/935","targetHints":{"allow":["GET"]}}],"collection":[{"href":"http:\/\/blog.stevenreidbordmd.com\/index.php?rest_route=\/wp\/v2\/posts"}],"about":[{"href":"http:\/\/blog.stevenreidbordmd.com\/index.php?rest_route=\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"http:\/\/blog.stevenreidbordmd.com\/index.php?rest_route=\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"http:\/\/blog.stevenreidbordmd.com\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=935"}],"version-history":[{"count":6,"href":"http:\/\/blog.stevenreidbordmd.com\/index.php?rest_route=\/wp\/v2\/posts\/935\/revisions"}],"predecessor-version":[{"id":943,"href":"http:\/\/blog.stevenreidbordmd.com\/index.php?rest_route=\/wp\/v2\/posts\/935\/revisions\/943"}],"wp:attachment":[{"href":"http:\/\/blog.stevenreidbordmd.com\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=935"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"http:\/\/blog.stevenreidbordmd.com\/index.php?rest_route=%2Fwp%2Fv2%2Fcategories&post=935"},{"taxonomy":"post_tag","embeddable":true,"href":"http:\/\/blog.stevenreidbordmd.com\/index.php?rest_route=%2Fwp%2Fv2%2Ftags&post=935"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}