Because we are all strapped for time, it’s encouraging to note that these benefits were achieved with far less impact on the work life of doctors and their staffs than anticipated. Few PCPs reported requiring more time with visits or to prepare their notes. E-mail traffic from patients remained unchanged. Tellingly, none opted to discontinue participating in open notes at the end of the yearlong intervention period. Most doctors were astonished by how little effect the intervention had on their practices, although a sizable minority reported changing the way they wrote their notes.
In simple English, watch the adjectives you use. I recently saw a lovely patient who happened to have a palpable spleen. I told her how impressed I was by her splenomegaly since I don’t often get to observe this finding. Having been recently discharged from the hospital following a lengthy stay, she replied that she never wanted to be told by a doctor that she might be impressive in any way. We agreed that, in medicine, boring is a beautiful word.
Cynical readers may question whether the data derived from pilot studies in primary care or oncology practices apply to rheumatology, a specialty replete with diagnostic uncertainty.
A pilot study from The Netherlands was among the first to assess the impact of open records in a rheumatology practice.4 The investigators focused on 360 patients with rheumatoid arthritis (RA) who were given the opportunity to freely access their entire record using a secure access portal. The results mirrored those described earlier. The majority of patients felt that having access to their notes and results made them more involved in their care. Their knowledge about RA, communications with their care providers and their trust in them all increased.
Clinical practice has taught us that patients who are engaged in their care are more likely to experience better outcomes. Thus, the consistent results from these pilot studies are encouraging and suggest that clinicians should not be apprehensive about adopting transparent medical records. To paraphrase Sir Winston Churchill,
clinicians have nothing to fear but fear itself.
In ICD-9 there are eight codes for rheumatoid arthritis (RA) and juvenile RA combined. Would you believe there are now 268 codes for RA [in ICD-10]? Paradoxically, this highly redundant system remains woefully incomplete. In RA, ICD-10 lacks codes for ocular complications, atlanto-axial or cricoarytenoid disease, & CCP antibody status is completely ignored.
Who Else Wants to Read Our Notes?
Patients are not the only parties interested in reading their notes. The disease coders and note auditors are also waiting in the wings for their opportunity to read what you wrote. After all, medical records have become a huge business. The transformation of the previously quaint medical record industry to a multibillion-dollar concern is a fairly recent phenomenon. Its timeline begins in 2005 with the release of a RAND Corp. study about the future role of EHRs, paid for, in part, by a group of companies that stood to profit by developing and selling EHR systems to hospitals and physician practices. The report predicted that widespread use of electronic records could save the U.S. healthcare system at least $81 billion a year, a figure RAND now admits was overstated.5
