Clinical Notes: Why Sharing Them Improves Care
The Proven Benefits of Healthcare Transparency Far Outweigh the Risks—Here’s What Studies Show
For fifty years, full patient access to clinical notes has been a heavily debated topic. OpenNotes, the international movement advocating for greater healthcare transparency, has swept through the industry, challenging previous barriers to vital health information. As a result of the movement’s research and advocacy, the healthcare industry has undergone many notable changes recently.
In April of 2021, the 21st Century Cures Act was implemented by the federal rule on Interoperability, Information Blocking, and ONC Health IT certification. This legislation finally permitted patients to access their electronic health information for free and “without delay.” It’s now possible for patients to legally and practically access their information without confronting costly, time-consuming barriers.
Further advancing the movement, platforms like intakeQ have successfully continued to improve healthcare transparency by facilitating access to shared treatment notes. As a result, patient engagement, adherence rates, and the quality of care have greatly improved.
Still, despite these clear benefits, several concerns about shared access to treatment notes remain.
If you’re weighing the pros and cons of sharing everything you write down with your patients, your concerns are valid. However, here are the benefits to consider, along with how you can avoid getting overwhelmed in the process.
The Research-Backed Benefits of Sharing Treatment Notes
Founded in 2010 by primary doctors, the OpenNotes movement conducted a year-long study of 20,000 patients. The research monitored patients’ access to their treatment notes online via secure portals. The results were telling, expanding the decades-long conversation to include the data necessary to move forward.
Years later, additional studies, along with 2020’s pandemic, further reinforced the movement for transparency in healthcare. As a result, most providers support full patient access. Even further, they would recommend the process to other practices, underlining the positive changes it’s made. Here’s what they discovered:
1. Improved Patient Engagement
Prior to the 21st Century Cures Act, patients endured a lengthy and discouraging process to access their clinical notes. They also found it challenging to participate in their treatment since most of their communication only occurred verbally. This caused misunderstandings or misremembered details, making care guidelines harder to follow. And with a less active role in managing their health, they experienced more gaps in their care.
As such, one study found that 70% of patients with access to their treatment notes felt more in control of their care. With improved transparency, patients didn’t have to guess what was in their notes and wonder about their health. They were also able to ask more informed questions and actively participate in discussions. This allowed them to better understand their treatments and progress.
2. Higher Treatment Adherence Rates
Poor medication adherence has costly consequences, with the healthcare industry reporting losses of around $300 billion annually due to non-adherence. Reducing this burden is a tall order, but it’s an achievable goal with healthcare transparency.
One of the benefits of shared notes (and improved patient engagement) is better adherence to treatment. In fact, most patients (66%) stated their clinical notes helped them to remember their care plans more easily.
Before shared access, strictly verbal interactions and ambiguous treatment plans led to poorer patient outcomes. With access to their notes, patients were able to have a clearer understanding of their diagnosis, treatment plan, and recommendations.
3. More Collaborative Care
With more healthcare transparency, patients and providers in the studies noticed it was easier to exchange information and collaborate. This is likely a result of improved patient engagement. When patients are more engaged, they can help coordinate communication and information-sharing between different healthcare providers involved in their treatment.
As a result, all providers gain a complete understanding of the patient’s health history, current treatments, and progress. And with a clearer understanding, patients receive more accurate diagnoses and targeted interventions.
Moreover, improved collaboration enables seamless transitions between healthcare settings. Patients can provide their medical notes to each provider, ensuring all relevant information is available during treatment planning.
4. Fewer Medical Errors
Poor communication is one of the leading causes of medical errors. Without detailed treatment notes, ambiguous or incomplete information can leave patients filling in the blanks. This can have serious consequences.
In fact, in an investigation of 23,000 malpractice lawsuits, it was found that more than 7,000 were due to miscommunication. Such errors resulted in $1.7 billion in malpractice costs and nearly 2,000 preventable deaths.
In OpenNotes’ study, 29% of the 331 patients who contacted doctors about their notes wanted to fix an error. As such, improved communication and patient involvement enabled patients to seek clarification and identify discrepancies that were overlooked.
5. Enhanced Patient Satisfaction
Overall, letting patients access vital information pertaining to their health is likely to improve their satisfaction. OpenNotes’ research shows that 37% of patients reported feeling somewhat or much better about their doctors following shared access.
Similarly, the majority of participating providers perceived their patients as happier with their experiences. With collaborative, engaging, and transparent care, providers were able to meet their patients’ needs and expectations.
Concerns with Sharing Notes
Naturally, you may have reservations about how sharing clinical notes could impact your office’s efficiency and patient care approach. Key concerns and findings from the OpenNotes project include:
- Time consumption: Initially, physicians feared that answering queries about treatment notes via phone calls, emails, and letters would be time-consuming. However, post-study, only 7% of patients reached out with concerns, with 85% being satisfied with the resolutions.
- Patient disagreement: Nearly half of the doctors anticipated disagreements with their clinical notes, prompting them to consider altering their language to prevent confusion. Contrary to these concerns, most patients understood their notes clearly, resulting in a stronger patient-doctor bond and increased trust levels.
Overall, the apprehensions were largely unfounded. If anything, the transparency of shared notes fostered closer relationships and enhanced understanding between patients and doctors.
Addressing Potential Issues
While most providers and patients have been happy with clinical note-sharing, it’s still preferable to have measures in place to avoid problems. Here are some practical steps to make sharing treatment notes a seamless, stress-free process:
- Educate patients about the purpose and content of clinical notes. Encourage them to read the notes and let them know it’s an opportunity to better understand their health and treatment plan.
- Establish communication channels so patients can reach out with questions or concerns. You can do this with a designated email address or a secure messaging system.
- Invest time in developing clinical notes that are easy to understand, using clear and concise language. With intakeQ’s Treatment Notes feature, you can create customized notes using various question formats, ensuring that you communicate information to your patients in a clear and comprehensive manner.
- Foster a culture of openness and trust with your patients. Encourage them to share any concerns or disagreements about their clinical notes. Addressing these issues together can strengthen the patient-provider relationship and reduce potential conflicts.
- Always improve. Regularly review your processes and seek feedback from patients and staff to see what you can do better.
By continually refining your approach to sharing clinical notes, you can minimize concerns and maximize the benefits for both patients and your business.
intakeQ: Join the Movement to Share Treatment Notes Effortlessly
Altogether, the benefits of sharing clinical notes with patients are numerous and significant. From increased patient engagement to improved treatment adherence, medical transparency has been enormously positive. And while there are concerns, studies have shown that the majority of patients and healthcare providers experience positive outcomes when embracing transparency in healthcare.
intakeQ plays a crucial role in healthcare transparency today by making it easier and more efficient to share clinical notes. The platform’s Treatment Notes feature, driven by the versatile intake form engine, provides a wide range of question formats, diagram-drawing capabilities, and attachment options. This flexibility makes the creation and sharing of notes a more streamlined and personalized experience.
With intakeQ, clinical notes are more than just static documents. They transform into dynamic tools for communication, education, and collaboration, simplifying the clinical narrative for patients while providing you with an accurate view of your patients’ healthcare journeys. And by leveraging its capabilities, you can provide both transparency and higher quality care.
References
DesRoches, C. M., Leveille, S., Bell, S. K., Dong, Z. J., Elmore, J. G., Fernandez, L., Harcourt, K., Fitzgerald, P., Payne, T. H., Stametz, R., Delbanco, T., & Walker, J. (2020). The Views and Experiences of Clinicians Sharing Medical Record Notes with Patients. JAMA Network Open, 3(3), e201753. https://doi.org/10.1001/jamanetworkopen.2020.1753
Effects of Poor Communication in Healthcare. (n.d.). HIPAA Journal. https://www.hipaajournal.com/effects-of-poor-communication-in-healthcare/#:~:text=Poor%20communication%20could%20lead%20to
Federal Rules Mandating Open Notes. (2023, March 1). OpenNotes. https://www.opennotes.org/onc-federal-rule/
Our History: Fifty Years in the Making. (n.d.). OpenNotes. https://www.opennotes.org/history/
Walker, J., Leveille, S., Bell, S., Chimowitz, H., Dong, Z., Elmore, J. G., Fernandez, L., Fossa, A., Gerard, M., Fitzgerald, P., Harcourt, K., Jackson, S., Payne, T. H., Perez, J., Shucard, H., Stametz, R., DesRoches, C., & Delbanco, T. (2019). OpenNotes After 7 Years: Patient Experiences with Ongoing Access to Their Clinicians’ Outpatient Visit Notes. Journal of Medical Internet Research, 21(5), e13876. https://doi.org/10.2196/13876
Yu, M. M., Weathers, A. L., Wu, A. D., & Evans, D. A. (2017). Sharing Notes with Patients. Neurology: Clinical Practice, 7(2), 179–185. https://doi.org/10.1212/CPJ.0000000000000335