Inviting Patients to Read Their Doctors’ Notes

Join Our Mailing List 

OVER HEARD IN THE DOCTOR’S LOUNGE

DEM white shirt

By Dr. David E. Marcinko MBA CMP™

In an OpenNotes study, researchers examined the impact on patients and doctors when patients were allowed access to their doctors’ notes via a secure Internet portal.

Through the use of surveys, patients’ benefits, concerns, and behaviors, as well as physicians workload, were measured.

The Study

Beth Israel Deaconess Medical Center (BIDMC) in Boston, Geisinger Health System (GHS) in Pennsylvania, and Harborview Medical Center (HMC) in Seattle were selected for this quasi-experimental year-long study.

The study included 105 physicians and 13,564 of their patients. Patients were notified when their notes were available, but whether or not to open the note was at their own discretion. The authors analyzed both pre- and post-intervention surveys from the physicians who completed the study; 99 physicians submitted both pre- and post-intervention surveys. Of the patients who viewed at least one note, 41 percent completed post-intervention surveys.

***

Physician Executive

***

Almost 99 percent of patients at BIDMC, GHS, and HMC wanted to have continued access to their visit notes at the completion of the study; no physician elected to end this practice.

Assessment

Although a limited geographic area was represented, the positive feedback and clinically relevant benefits demonstrate the potential for a widespread adoption of OpenNotes.

Moreover, it may be a powerful tool in helping improve the lives of patients.

Citation: Inviting Patients to Read Their Doctors’ Notes: Author(s): Delbanco, T; Walker, J; Bell, SK and Darrer, JD et al: American College of Physicians, Annals of Internal Medicine, October 2012

Open Notes, a grantee of the Robert Wood Johnson Foundation, was developed to demonstrate and evaluate the impact on both patients and clinicians of fully sharing (through an electronic patient portal) all encounter notes between patients and their primary care providers.

Conclusion

Your thoughts and comments on this ME-P are appreciated. Feel free to review our top-left column, and top-right sidebar materials, links, URLs and related websites, too. Then, subscribe to the ME-P. It is fast, free and secure.

Speaker: If you need a moderator or speaker for an upcoming event, Dr. David E. Marcinko; MBA – Publisher-in-Chief of the Medical Executive-Post – is available for seminar or speaking engagements. Contact: MarcinkoAdvisors@msn.com

OUR OTHER PRINT BOOKS AND RELATED INFORMATION SOURCES:

bmp

http://www.BusinessofMedicalPractice.com

***

Altered Medical Records – OLD SCHOOL!

Join Our Mailing List

ON ALTERED RECORDS

By Dr. David Edward Marcinko MBA CMP®

http://www.CertifiedMedicalPlanner.org

DEM white shirtThe health care provider should not alter the medical record under any circumstances.

The office, clinic or hospital must zealously guard its medical records from alterations by physicians or members of the nursing staff.

Even an inconsequential alteration will throw the validity of the entire record into question. If an entry must be changed, a single line should be drawn through the entry, taking particular care to make sure that the original entry is clearly legible. The new entry should be written above or next to the old entry, and the date of the new entry, as well as the name of the person making the entry, should be recorded. The entry must also be signed by that person.

Juries are very intolerant of altered medical records; and even innocent mistakes, such as the loss of a few pages of a record, will be construed as an intentional cover-up. Under no circumstances should materials such as liquid paper or other opaque liquids be applied to the record in order to correct any entry.

Assessment

The health care provider should not alter the medical record under any circumstances.

Conclusion

Is there an emerging migration back to paper medical records?

Your thoughts and comments on this ME-P are appreciated. Feel free to review our top-left column, and top-right sidebar materials, links, URLs and related websites, too. Then, subscribe to the ME-P. It is fast, free and secure.

Speaker: If you need a moderator or speaker for an upcoming event, Dr. David E. Marcinko; MBA – Publisher-in-Chief of the Medical Executive-Post – is available for seminar or speaking engagements. Contact: MarcinkoAdvisors@msn.com

OUR OTHER PRINT BOOKS AND RELATED INFORMATION SOURCES:

Risk Management, Liability Insurance, and Asset Protection Strategies for Doctors and Advisors: Best Practices from Leading Consultants and Certified Medical Planners™

 Harvard Medical School

Boston Children’s Hospital – Psychiatrist

Yale University