Open Notes

After I had a surgery a couple of years ago, I requested a copy of the discharge summary to add to my records. It was no surprise that there were a couple of errors. “Would you like information on quitting smoking? –what??!!” A template entry error suggested that I smoked, explaining why a well meaning nurse gave me some confusing streamates counseling. I found a few other slight variations from reality in my interviews with several providers. This morning I jogged to a Annals of Internal Medicine podcast discussing a recent jasmin live article, “Open Notes” a description of a pilot project being done by 100 physician and 25,000 patient volunteers. In this upcoming project, patients will receive an email after clinic visits allowing them access to their clinical progress notes. This type of access on shouldn’t be particularly shocking. Patients have legal rights to review notes. But… the system doesn’t make it easy - there are obstacles- some are human, and some are technical. However in many settings we have increasing collaboration between doctor and patient (evisits are collaborative) to create documentation. Patients have access now to many parts of their record. Many physicians are putting assessment and plan documentation into a visit summary that patients may take home on paper, or jasminelive review on line. This is important because we know that only about 1/2 of what is heard is recalled correctly by patients in the course of a sometimes stressful, and often hurried clinic visit. But what about the other parts of documentation- the medical history and the physical findings? There is an obvious advantage to open notes- getting the facts correct! …if there’s any correction that needs to be done or miscommunication, it can get straightened out right away…I think [allowing patients to read their doctors' notes] is going to make things a lot better in the long run. - An engineer patient, quoted from the Annals article Pros and Cons? Physicians worry about many calls or emails about clarifications for trivial errors or technical phrases (”patient is SOB” = short of breath?); Some thought their notes would need to be less precise; Some where embarrassed about their writing style. Doctors also worry that patients would draw inappropriate conclusions - becoming cardiac “cripples” or worrying about cancer from a few speculative words. On the other hand, benefits include efficiencies in communication, beneficial clarifications, and more patient and family engagement. - powerful. Patients are also ambivalent. Patients also worried about hearing something they were not ready to know, or hearing what the doctor was thinking about them, or something that would shake confidence. But open notes seem to many patients like a next logical step in heath care transparency with benefits parallel to those seen by doctors- accuracy, engagement, collaboration… Discussion in the podcast speculated about whether doctors would learn to document with different words. Words like “obesity” have specific clinical meaning but are socially charged. I might use more plain and descriptive language…. overweight, high (or low) risk? Would doctors use “private notes” for the occasional need for personal speculation? -maybe sometimes. Notes are more frequently templated - capturing discrete factoids vs narrative of the past- is this good? Dr Delbanco, lead author, anticipates that notes will become more collaborative and even signed by both participants as a sort of contract for care. This sort of disruptive change, may open the door to many unanticipated changes!

Medical Myths

Some medical myths dispelled by authors from Indiana Univ - I listened to during my morning jog from the National Library of Medicine PubMed podcast: Myth: Adults should drink 8 glasses of water a day. This is a suggestion from the 1940’s that has no supporting evidence. In fact you can cause harm by drinking excess water. Myth: Humans use only 10% of their brainpower. Evidence from imaging studies is that most of the brain is active all the time. Myth: Hair and fingernails grow after death. Uggggh - not. Myth: Shaving causes hair to grow back faster, darker, coarser - not. Myth: Reading in dim light causes eye damage - maybe strain but not likely damage. Myth: Eating turkey makes you drowsy - there isn’t enough tryptophan, but a heavy meal can make you drowsy. Myth: Cell phones cause electromagnetic interference in hospitals- no evidence. In fact, a study of anesthesiologists showed that use of phones improved communication and was beneficial in reducing medical errors.

Risky CT scans

Getting more information by doing imaging tests can only be good, right? Not always. Americans are the most irradiated people in the world according to this article on the use of CT scans in the US. About 10% of Americans have a CT scan each year! The amount of radiation exposure varied as much as 13 fold in one study, however with renewed attention to the lifelong effects of radiation radiologists are working to make sure that CT scans use the lowest possible amount of radiation. Scans are over used in general however. It is easy to order them, sometimes malpractice concerns arise, and getting a scan is simply built into many ED protocols. One estimate is that 1/3 of scans are not needed. I ordered an abdominal CT yesterday to help sort out the source of abdominal pain for one of my patients. The pain was kinda suspicious for appendicitis, but not all the classic signs were there. CT scanning has in recent years reduced the removal of a healthy appendix from about 1/4 to 3%- beneficial, but should a CT scan be done when the findings make the likelihood of appendicitis really high? An article in this weeks New England Journal of Medicine makes the point that CT scanning should be used judiciously. That radiologists should act as consultants on type of test and whether there is benefit for a test. The point is made that this type of diagnostic test is best used in cases when suspicion of a condition is neither very high or very low- in other words the imaging information is useful in making a decision. Patients should ask “how will this test help in my treatment?” Better ordering decision support in our electronic health record will help. When a CT scan is ordered, a physician must specify what the diagnostic question is - and there will be feedback on the utility of the test- will the test be useful for this question…or not. Our challenge is to make this useful and not hindrance to care.

Things you can do on-line

You can…
1) make an appointment on line.
2) look up doctor- information and quality results
3) contact your care team, or physician for an evisit
4) refill a prescription
5) review test results
6) use the health information library for reliable medical info
7) look-up health reminders/immunizations
8) plot and graph lab, weight, blood pressure information
9) review your medical problem list and histories
10) review past appointment notes- from the after visit summary