OpenNotes – The Way Forward in Improving Medical Documentation

Doctor-patient relationship

The field of medicine has always been at the forefront of technological advancement. This is true of the way healthcare professionals and clinicians have administered treatments and practiced medicine and also of the strategies and practices in which they use medical documentation. From the first recorded medical notes, which were recorded in 1800 BC in Egypt, to the latest advancements in medical dictation and note-taking, those practicing medicine have always required effective documenting procedures and tools. Medicine has come a long way from the papyrus scroll to electronic health records (EHRs) and innovative productivity tools such as Chartnote.

The need for these tools has become more vital than ever for healthcare practitioners in recent months. With the passing of the 21st Century Cures Act, the new Federal Rules on Interoperability and Information Blocking took effect. This has changed the laws around the availability of patient’s electronic health information. These changes have a direct effect on how clinicians need to make their documentation available to be viewed by their patients. This includes the notes of their interactions with their patients, as well as their test results.

The Federal Rules on Interoperability and Information Blocking

As of April 5th, 2021, healthcare providers are required to give patients access without charge to all the health information in their electronic medical records “without delay.” The main goal behind these changes is to end information blocking practices. These types of practices make it difficult for patients, doctors and organizations to use health information in electronic medical records by impeding the secure exchange and use of that information. Essentially, the rules aim to move away from a system where healthcare organizations may share data to a system where they must share data.

There are some great resources available for healthcare providers that break down these changes. Informational videos and blog posts available at the AMA website and at OpenNotes, that do a great job of laying out the new changes and how they apply to your practice. These are the key insights and takeaways from the Final Rule.

The Office of the National Coordinator for Health Information Technologies (ONC) has defined some key terms, including “electronic health information (EHI)” and “information blocking” as well as activities that may be considered as likely to interfere with the use or access of EHI. They have also referred to and defined the term “actors”, who are either healthcare practitioners, health information networks or exchanges and EHR vendors.

There are guidelines and rules that developers of applications and IT software must follow to comply with these regulations. They include product development and testing guidelines as well as the limitation of certain business practices, such as charging for access to EHI or fees to transfer patient information to another EHR provider.

 They have laid out the types of clinical notes that absolutely must be shared, “without delay”. These are:

  • History and physical
  • Progress notes
  • Consultation notes
  • Discharge summary notes
  • Procedure notes
  • Imaging narratives
  • Laboratory report narratives
  • Pathology report narratives

They have also made clear the exceptions to this rule. These can be viewed in full here but in short, they fall in these categories. Harm prevention, privacy, security, infeasibility and health IT performance. There are also certain conditions for exemptions that involve procedures for fulfilling requests to access that information.

How does this Add Value?

There is an ongoing debate about the impact of the benefits of these policy shifts in contrast to the potential negative effects. The predictable benefits are twofold. 

Patients who have access to their medical information have been found to better understand their diagnosis and better remember their care routines, including medication schedules and treatments. This should create better health outcomes for the majority of patients who are receiving care.

The other main predictable benefit has to do with the relationships that clinicians build with their patients. The line of communication between doctor and patient can be strengthened by this change in policy. By seeing their doctors’ notes, the patients can see how well their doctors are listening to their concerns and may be pleasantly surprised to see that doctors are intently listening to them. Trust grows when people believe they are being heard. This should enable healthcare providers to have higher quality conversations with their patients.

There is a group of clinicians and healthcare practitioners that aren’t so optimistic about the idea. They believe that the open availability of their notes to their patients will cause them to change the way they write their notes, tempering their thoughts so as not to offend. 

The other concern is that patients may receive serious test or diagnostic results before their doctors have a chance to create context and explain for them what these results mean. This can create anxiety for patients. Cancer diagnoses and serious test results need to be delivered in a way that helps the patients understand and cope with the results and some doctors believe that this process of explanation will not happen with the implementation of this new system.

Plato famously said, “our need will be the real creator”. This transformed over the years to “necessity is the mother of invention”. Both proverbs are true in the sense that when there is a need, a solution will inevitably come forth. The necessity for a powerful and effective note sharing tool in the medical field is more important now than ever before.  

What is OpenNotes?

It is important to note that OpenNotes is not software or a product. It is a call to action. OpenNotes is the international movement promoting and studying transparent communication in healthcare. The goal is to help patients and clinicians share meaningful notes in their medical records. The research being done by OpenNotes supports the supposition that when clinicians and patients and their families share transparent notes, their quality and safety of care improves. 

The movement has been 50 years in the making. Since 1973, after the publishing of a landmark article in the New England Journal Of Medicine, there has been a push for allowing patients to have a more active role in their health through access to their medical records. 

From that point to the present day, there has been incredible progress towards this goal, culminating in the passing of the Cures Act and its rules around the accessibility of medical notes for patients.

How do you Improve your Medical Documentation?

Documenting Sensitively in OpenNotes 

For many, OpenNotes will not change how we practice or chart. Here are some tips to consider in your documentation to optimize sharing of your notes with patients:

  • Expect patients to read, download and share your notes.
  • Describe problems and facts clearly and neutrally.
  • Keep an updated and accurate medication problem list.
  • Accurately document history of present illness (HPI), review of systems (ROS), and physical exam findings. If you use dot phrases and templates, make sure you edit the default documentation to accurately reflect the patient’s presentation.
  • Incorporate pertinent laboratory or study results that have been reviewed.
  • Be mindful of defaulted verbiage in your templates.
  • Offer a balanced perspective describing the patient’s achievements since the last visit along with documentation of clinical problems.
  • Consider alternatives to words that could be considered as accusatory, inflammatory or reveal frustration with the patient.

Consider avoiding the following in your documentation:

  • Your notes should be clear, both to patients and other clinicians. Don’t oversimplify your notes.
  • Do not omit sensitive issues such as obesity, substance abuse, mental health, suspicions of life-threatening illness, etc.
  • Avoid using pejoratives e.g., fat, angry, resistant.
  • Don’t include jargon or abbreviations such as SOB (easily misinterpreted) or BID (not easily understood).
  • Refrain from documenting that the patient arrived X minutes late to the appointment.

Timely Completion of Medical Records

Healthcare practitioners already have incredibly demanding workloads. New regulations around their medical notes may not be an exciting prospect to them. Medical documentation is one of the leading causes of clinician burnout. To address this problem, Chartnote has created a productivity tool for healthcare professionals to be more efficient when completing medical documentation. Clinicians should invest their time where they add the most value. That is in front of their patients, not their computers. 

Chartnote has also developed a voice recognition solution that allows you to dictate your notes. This can increase your note-taking efficiency from 35 words per minute, which is the average for a doctor, to 130 words per minute. We add value to clinicians so they can add value to their patients.

Dictating your notes and using templates to build documentation in the medical record can improve the quality of your notes. It has the added benefit of having clearer documentation without the need of using acronyms or abbreviations. The lack of adequate and timely documentation can adversely affect patient care.

Using snippets or smart phrases can also help you to automatically convert or autocorrect commonly used words that you may now want to avoid. For example:

Commonly used wordPreferred documentation
RefusesDoes not agree with […]
Patient declines […]
DeniesPatient states he/she did not […]
Insists or demandsFeels strongly about […]
Strongly requests […]
AngryFeels upset about […]
Patient states […]
Did not meet his/her expectations
NoncompliantWas unable to follow through with […]
Patient has been non-adherent to […] due to […]
Poor historianPatient was unable to recall
Drug seekingI have concerns about the patient’s medication request or use. Medications are not resolving the issue. Other treatments were discussed.
Recent lab results did not find traces of […] despite the patient report he/she has taken at […] time. These concerns were discussed with the patient and other alternatives reviewed.
Patient notes challenges and frustrations with provider’s or specialist’s recommendations, noting that they may need to seek other alternatives which may not be in their best interests, should the current treatment be removed.
ParanoidContinues to have thoughts/concerns/fears that […]
Morbid obesityBMI > 40, severely obese per medical criteria.
Documenting sensitive parts of the patient’s history using Chartnote.

 Setting Up Expectations for Lab or Imaging Results

Following these four tips can avoid many messages or calls into the office from patients anxious about their lab or imaging results:

  1. Inform the patient who (doctor, nurse, staff, etc.) will follow up with the results and how and when to expect it. For example: “I will order X lab/imaging test, I will review them and will send you a letter/portal message in about X days (give a range). If there are any abnormal results my MA will give you a call with my instructions”.
  2. Normalize and anticipate that some labs or images might be flagged as abnormal. 
  3. Let the patient know that if you are concerned about any of the labs/images you will contact them before all results are received. Make sure patients know that sometimes lab results are best interpreted together, and you may have to wait for all the results.
  4. Consider a pre-scheduled lab/imaging review follow-up appointment when appropriate.

Some more examples of how to communicate with your patient:

  • “It is very common for some lab results to be out of range and flagged as abnormal. I want to assure you that if any of the results I review are concerning I will contact you right away”.
  • “I might have to wait until all the lab or imaging results are ready for me to review. I might also need to discuss the results with the specialist before contacting you”.

If you have to deliver bad news it is better to do it in person or at least by phone. Never leave a voicemail or send a message with unpleasant or unfortunate news.

Was OpenNotes implemented in your practice? How did it go? Did it alter the way you document your notes? Tell us more about your experience in the comment section below.

Discover Chartnote – We are passionate about preventing physician burnout by decreasing the burden of medical documentation.

About Chartnote

Chartnote is revolutionizing medical documentation one note at a time by making voice-recognition and thousands of templates available to any clinician. We know first-hand that completing notes while treating patients is time-consuming and an epic challenge. Chartnote was developed as a complementary EHR solution to write your SOAP notes faster. Focus on what matters most. Sign up for a free account:

Posted on: May 25, 2021, by :

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