Why the VA Embraces OpenNotes

Apr 16, 2013, 3:15 PM, Posted by

Susan Woods, MD

Earlier this year, the Department of Veterans Affairs (VA) embraced OpenNotes, enabling more than 1 million veterans who currently have access to the VA personal health record to view or download their own medical notes along with their health record information via the My HealtheVet Blue Button. In a recently published study in the Journal of Medical Internet Research (JMIR), the VA's Susan Woods, MD, MPH, a longtime champion of open access and transparency, examined patients’ views and experiences with reading their health records, including clinical notes. The study is the first qualitative look at VA patients’ experiences viewing electronic records that included clinical notes and lab test results. Woods and her colleagues showed that viewing records and notes appeared to empower patients and increase their involvement in their own care but Woods says new communication skills will be needed to optimize the user experience.

In a recent interview, Woods discussed the power of open medical notes for patients and clinicians.   

What has been the biggest concern that doctors and others have raised about open notes?

Clinicians worry that opening notes may cause patients stress, or feel that reading notes may even cause patients harm. Clinicians feel vulnerable, with concerns about being judged or that their workload will increase. They worry more time will be spent explaining things to patients or responding to a rise in emails from patients trying to decipher their notes. Such concerns are valid, but the increasing experience and research suggest that these assumptions won’t entirely be borne out.

How do you combat resistance among clinicians?

One focus at VA has been to help health professionals recognize that patients have been accessing their records all along. All patients have a legal right to their medical information, and many take advantage of that and get copies of their records. For this to be successful, though, clinicians need to not only be aware of open notes, but to also embrace the idea.

We also talk about how electronic access doesn’t change policy, but lowers a barrier for patients. We’ll need to show how patients can become more trusting, the visit isn’t longer, and the encounter isn’t more stressful to the clinician. Yet telling clinicians that they shouldn’t be fearful won’t make it so; they’ll need to see it for themselves.

We’ll also need to validate that a few patients will require more time, and more skillful communication, after having read their notes. The other thing to keep in mind about clinical workload is that open notes are just one piece of the available electronic patient tools.  We should not think about the open note by itself. It should be viewed in the context of all tools available to patients that further engage them in care.

Open notes seemed to push patients to become more active participants in their own care and be more prepared."

Will doctors and other health professionals need to think more carefully about how they write notes?  

The words we use – substance abuse, personality disorder, morbid obesity, patient noncompliance – need to be examined. We have to work together and improve how we communicate with patients. Our recent study shows that patients may be offended by what they perceive is a derogatory tone in notes. Our language and how we document need to evolve. I strongly believe that opening up medical notes to patients will spur an evolution of what our notes are even for.  We need to be mindful that the patients we write about are looking at these notes. If we want patients as part of our team, then we need to write in ways that encourage partnership. I’m not supporting abandoning medical language, but we can’t write about our patients like they’re not in the room!

How do you encourage physicians and others to be more mindful of their readers?

The first thing we’ve done is convene a broad stakeholder group--including leaders in primary care, social work, mental health, ethics, nursing, system re-design, and others. We talk about what we need to be doing with open notes. We are trying to find core messages that can resonate with our health care teams as we all go down this path. We’ve come up with some initial main points.

What are those points?

First and foremost, be mindful that your writing will be read by patients, caregivers, and families.

Second, avoid judgmental language and words that could be misinterpreted. The note is not only a place to document care, but it also is a way to communicate with other members of the health care team. That communication can’t have emotional baggage.

Third, listen to your patients when they come back and talk about what they see in the notes.  They are experts in living with their own health issues. If they have concerns about what was written or wasn’t in there, you need to appreciate and elevate their perceptions and concerns. If we really want participatory medicine, we need to listen to our patients.

What are some of the JMIR study’s key “takeaways” that will help inform the field? 

Our study showed that open notes were positive for patients. It was a communication tool that patients could use to help them remember and help them plan. They told us they learned more about their own health issues and said they worked harder at their own self-care as a result of having access to their health information.

What was the most exciting finding?

Open notes seemed to push patients to become more active participants in their own care and be more prepared. They asked better questions at their visit; it reminded them of things they needed to follow up on, particularly things like repeat testing. One patient we interviewed learned she had anemia and needed to be on iron and asked about it at the next visit.  In the patient’s eyes, they felt like they played an active role in their own care and could remind providers of things that may have slipped through the cracks.

What is the biggest takeaway for patients and clinicians?

Trust has been identified as an intermediary element for better health outcomes. I believe the transparency of open notes will result in higher trust between patients and health professionals and better health outcomes for patients. This is an area we should study further. 

Should medical and health professions schools be doing more to prepare doctors to write notes that engage patients? 

The younger generation is more inclined to use electronic tools for all purposes, but the issues of transparency and being mindful and professional, and using words to engage patients, need to be integrated into our training of health professionals. We need groups like the American Board of Internal Medicine (ABIM) and other accrediting boards to make this a priority in training for everyone who writes notes – doctors, nurses, pharmacists, medical assistants, and social workers. We’ve got to spread this across all disciplines so it affects anyone who touches the record.

Susan S. Woods, MD, MPH, is a general internist, consumer informatics specialist and researcher at the Portland VA Medical Center and faculty at Oregon Health & Science University, Departments of Medicine and Medical Informatics & Clinical Epidemiology. At the Veterans Health Administration, she serves in the Office of Informatics & Analytics. Susan focuses on consumer health technologies as a way to engage patients and families in their health and care, and enhance the patient experience. She encourages disruptive change, innovation and transparency on her blog, Shared Health Data.

This commentary originally appeared on the RWJF Pioneering Ideas blog.