The old cliché "When it rains, it pours," is hardly more appropriate than in the world of health care. Every day, the industry changes, and we are forced to adapt to new regulations and expectations from the government, insurance companies, and patients that dramatically affect the way we practice.
Recently, the storms have been raging in the area of health IT. As an example, consider the initiative that began with a simple requirement for e-prescribing and then developed into a huge undertaking called "meaningful use."
It begs the question: Why is it that electronic health records, which were sold on the idea of making our lives easier, have only seemed to complicate things?
While there are certainly no easy answers, one thing is clear: Electronic records are here to stay, and they have had a significant impact on physician practice and patient care.
This month, we’ll explore the idea of implementing a patient portal, that is, granting patients immediate access to their medical records through the Web. This has evoked a tremendous amount of anxiety among physicians – and while these concerns are significant, they have not slowed the adoption of the new technology.
Unsealing the Sacred Book
There are a number of issues raised anytime a practice or health system decides to install a patient portal.
First and foremost, physicians become quite concerned about what a patient will see in their personal records, and how this will affect the doctor-patient relationship. This is particularly salient in areas such as mental health, social history, and life-altering diagnoses. A care provider may document something in a problem list or differential diagnosis that the patient could find shocking or offensive. Issues such as "morbid obesity" or "bipolar disorder," while perfectly legitimate and accurate, can be viewed as judgmental and insulting. Other comments, such as "possible malignancy" or "suspicious for multiple sclerosis," could be devastating to a patient who has not had time to process them with his or her physician.
It is critical, therefore, that providers are aware of what parts of the record will be available to the patient, and how to document sensitive issues appropriately. Most Web portals allow for customization and limits to be placed on what a patient can access. While it is true that patients have a right to the entirety of their record, it is not necessary to provide them with information they have not requested.
We would argue, however, that the standard should be to provide as much access as possible – a standard that has been adopted by many major health systems across the country. The onus is then placed on the doctor to be prudent in how he or she documents in the record, with full knowledge that patients can and will be reviewing it.
Why More Is (Usually) Better
Many of the people we speak to ask us whether or not we believe that sharing health records with our patients is a good thing. Until recently, we had only our own opinion, and had limited to no data to back it up. This all changed this month with an article by Dr. Tom Delbanco entitled "Inviting Patients to Read Their Doctors’ Notes: A Quasi-experimental Study and a Look Ahead" (Ann. Intern. Med. 2012;157:461-70).
In this study, more than 13,000 patients at multiple medical centers were given access to their physicians’ notes to see how reviewing them affected "behaviors, benefits, and negative consequences."
The results are quite interesting. Of the patients who reviewed their notes and answered follow-up surveys, 77%-87% felt more in control of their care, and 60%-78% reported better medication adherence. Only about a quarter of those surveyed had privacy concerns, and just 1%-8% reported that the notes caused "confusion, worry, or offense."
This study also examined physician behavior. Of the 105 primary care physicians involved across three states, 3%-36% reported changing documentation content, and many reported taking more time to write their notes.
In the end, the authors report that "99% of patients wanted open notes to continue, and no doctor elected to stop." Clearly, the process seemed to be beneficial for both physician and patient, and the benefits outweighed the risks.
Managing Liabilities
As our column last month pointed out ("How to Avoid EMR Legal Pitfalls," Sept. 15, p. 40), the use of electronic health records has unearthed some new legal pitfalls, and the realities of a patient portal further underscore this unfortunate fact. Patients – and their attorneys – are able to scrutinize their medical record, and any missed lab result or diagnostic error is available for anyone to see. This is a significant fear for many physicians, but so far history has proven the opposite to be true.
