Thursday, July 29, 2010

Another Issue For EHR Planners to Consider - This Will Be A Hard One!

There has been a good deal of coverage of this issue in the last few days.

Can deciphering your doctor's notes improve care?

By LAURAN NEERGAARD AP Medical Writer

Posted: 07/20/2010 12:07:31 AM PDT

Updated: 07/20/2010 08:33:52 AM PDT

WASHINGTON—Don't be offended if your doctor writes that you're SOB, or that an exam detected BS.

The aim is to help, not insult: A project is beginning to test if patients fare better when given fast electronic access to more of their medical chart—the detailed notes that doctors record about you during and after every visit. You just might have to look up some of the technical jargon, like those abbreviations for "shortness of breath" and "bowel sounds."

Didn't know about those notes? Researchers involved in the "OpenNotes" project say they are surprised at how many patients don't.

"You really have to be a partner with your doctor to do well," says Dr. Tom Delbanco of Harvard and Beth Israel Deaconess Medical Center, who heads the study and thinks better use of those notes will help.

"It's your body. It's your record. It's your illness. You should have ready access to everything about it."

Yes, your clinic may have an electronic records system that lets you log in to make an appointment, check your cholesterol test or review your medications. But Delbanco and nursing colleague Jan Walker have found few include those doctor notes that provide details about a patient's health.

They can stretch two or three pages, as doctors mull alternate diagnoses they may not have mentioned, like a test ordered to rule out cancer.

Or doctors may jot reminders about personal issues that could complicate care—maybe the patient ignores medical advice, or is in denial, or has financial difficulties.

Doctors may detail problems in more blunt terms than they'd used face-to-face.

Hence easier access is debated. Say the doctor carefully avoids the "O" word while urging you to lose 20 pounds, only to write that "Joe is obese." Will you get mad, or be more likely to follow the advice?

To find out, three large health centers—Beth Israel, the Geisinger Health System in Pennsylvania and Seattle's Harborview Medical Center—are enrolling 115 doctors and up to 25,000 patients in the OpenNotes study.

For a year, participants will get an e-mail after each office visit saying their doctor's note is available through a secure online portal. Researchers will track if patients read it and find errors, and how they use it. Doctors' habits are being tracked, too—if they censor themselves or write more patient-friendly notes.

More here:

http://www.mercurynews.com/latest-health-news/ci_15556642?nclick_check=1

The same topic has been addressed here

What are you hiding from patients in their medical records?

July 22, 2010 — 1:30pm ET | By Neil Versel

Editors Corner:

Many a physician is understandably apprehensive about entering the brave, new world of "meaningful use" of EMRs. After all, it's not easy to change the way you've done things for years. What they may be most apprehensive about is not the expense, the workflow modifications or the computer skills they have to learn, but rather the requirement that they be able to give patients copies of their medical records on demand. (Actually, patients have had a right to see their records since HIPAA came along, but meaningful use adds a new dimension.)

As you may have read in FierceHealthcare this week, providing patients access to their records--paper or electronic--could open up a "Pandora's box." Imagine reading that your doctor wrote "SOB" in your chart, for example. No, it's not a commentary on your personality, but medical-speak for "shortness of breath." Same goes for "BS," which means "bowel sounds."

What happens when a doctor dances around a topic such as obesity during an office visit, but then writes the word "obese" in the record? Some are worried that it turns the doctor-patient relationship on its head.

Those are but some of the findings from planning for the Robert Wood Johnson Foundation-funded "OpenNotes" demonstration project, which will study the dynamics of providing physician notes to about 25,000 patients at Beth Israel Deaconess Medical Center in Boston, Geisinger Health System in Pennsylvania, and Harborview Medical Center. Researchers studying OpenNotes plans reported their findings this week in the Annals of Internal Medicine.

More here:

http://www.fierceemr.com/story/what-are-you-hiding-patients-their-medical-records/2010-07-22

The Wall St Journal also provided coverage

What the Doctor Is Really Thinking

· By LAURA LANDRO

Some doctors are taking an unusual new approach to communicate better with patients—they are letting them read the notes that physicians normally share only with each other.

When patients finish a checkup, doctors record notes on a range of topics. A new study looks at what happens when those notes become available for the patient to read electronically. Laura Landro has details.

After meeting with patients, doctors typically jot down notes on a range of topics, from musings about possible diagnoses to observations about how a patient is getting along with a spouse. The notes are used to justify the bill, and may be audited. But the main idea is to have a written record with insights into the patient's condition for the next visit or for other doctors to see.

A study currently under way, called the OpenNotes project, is looking at what happens when doctors' notes become available for a patient to read, usually on electronic medical records. In a report on the early stages of the study, published Tuesday in the Annals of Internal Medicine, researchers say that inviting patients to review the records can improve patient understanding of their health and get them to stick to their treatment regimens more closely.

But researchers also point to possible downsides: Patients may panic if their doctor speculates in writing about cancer or heart disease, leading to a flood of follow-up calls and emails. And doctors say they worry that some medical terms can be taken the wrong way by patients. For instance, the phrase "the patient appears SOB" refers to shortness of breath, not a derogatory designation. And OD is short for oculus dexter, or right eye, not for overdose.

"If you are a patient that just goes in once a year for a checkup, the doctor's notes might be not that useful. But if you have a lot of medical problems, it helps you ask the doctor the right questions and lets you know what's going on," says Jeanne Hallissey, a patient at Beth Israel Deaconess Medical Center in Boston, who began reading her doctor's notes as part of the study.

Medical providers have been stepping up efforts to improve doctor-patient communication, in part because studies show it can result in better patient outcomes. The introduction of electronic medical records in recent years has allowed patients to contact their doctors by email, log on to secure websites to get lab results and get links to health information recommended by their doctors.

The year-long OpenNotes study, funded with a $1.5 million grant from the Robert Wood Johnson Foundation, involves 25,000 patients and their primary-care physicians at Beth Israel Deaconess, Geisinger Health System in Danville, Pa., and Harborview Medical Center in Seattle. "We want to break down an important wall that currently separates patients from those who care for them," says lead investigator Tom Delbanco, a Harvard Medical School professor who treats patients at Beth Israel.

Lots more here:

http://online.wsj.com/article/SB10001424052748704720004575377060985974450.html#printMode

And the

Should Patients Read the Doctor’s Notes?

By PAULINE W. CHEN, M.D.

Their request seemed simple enough: the patient and his wife, both in their 70s, wanted a copy of what I’d written in their medical file. During their visit, I had watched them refer to a well-thumbed collection of doctors’ notes and medication lists, so when they asked for a copy of my note just before leaving, I assumed it would simply be added to the others.

But when I mentioned the request to one of the nurses outside the exam room a few minutes later, her eyes grew wide.

“Oh no, you can’t do that,” she said, shaking her head. “I don’t think it’s legal.” The other doctors and nurses, attention piqued, moved closer to listen. “Send them to medical records,” she urged. “He can sign the release papers there.”

Another nurse in the growing crowd offered her own advice. “Do you know what’s going to happen if you give them a copy now?” she asked. “They’re going to start calling and e-mailing you with questions about what you wrote.”

The doctors and nurses began clucking in agreement. “Think about it for a second, Pauline,” one doctor said with voice lowered. “Maybe they are thinking of suing you.”

There was a collective gasp from the group now gathered around me; and I could guess what they were thinking as they craned their necks to peer into the exam room where my elderly patient was busy fussing with his papers as his wife stood adjusting the canvas fishing hat on his head.

The barbarians are at the gate.

For 40 years, the tension over patient access has been playing out in hospitals, clinics and doctors’ offices. Although medical records have always been accessible to clinicians, payers, auditors and even researchers, it was not until the 1970s that a few states began giving patients the same rights.

While a handful of physicians were vocal supporters of these early efforts, the majority of doctors were far less enthusiastic. They worried that their notes might become a source of unnecessary stress for patients. Read without an experienced clinician’s interpretation, slight abnormalities like an elevated cell count from a viral infection could turn into a life-threatening cancer in the eyes of patients.

Even routine abbreviations and jargon like “S.O.B.” (shortness of breath) and “anorexic” (a general lack of appetite, not the disease anorexia nervosa) could be confusing at best and inadvertently demeaning at worst. Doctors, already pressed for time, shuddered at the idea of suddenly being responsible for the worries of a reading public.

In 1996, despite these concerns, the Health Insurance Portability and Accountability Act, or HIPAA, gave all patients the legal right to read and even amend their own medical records. At the time, a group of national health care experts hailed this new transparency as a necessary component of better and safer care.

But today, few patients have ever laid eyes on their own records. And those who try often come back from their missions with tales of bureaucratic obstacles, ranging from exorbitant copying costs to diffident administrators. The same concerns from 40 years ago come up again and again, with little evidence to support or refute the claims of either side. Should medical records be shared as interactive documents between patients and physicians? Can transparency work, or will it end up worrying patients, muddling the patient-doctor relationship and adding more work to an already overburdened primary care work force?

Lots more here:

http://www.nytimes.com/2010/07/27/health/27chen.html?_r=1&hpw

All I can say is that this is a really interesting study and deserves to be followed closely. All the questions raised in the various commentaries associated with these articles have some considerable relevance and deserve consideration.

Of course just how this would and can work in an electronic world just adds to the potential complexity. If people really want this sort of access – and I am sure some will and some just won’t – it will be important to come up with an approach that meets each groups needs.

We also need to make sure that what is done is evidence based and sound. This means making sure that all patients are provided with the access they want and can comprehend while not forcing unwanted material on them.

Thinking caps on time I suspect!

David.

No comments: