Patients were supposed to be given unfettered access to their clinical records beginning November 2, 2020. Because of the pandemic, the enforcement date has been delayed until April 5, 2021. The “open notes” rule is a federal mandate designed to give patients immediate access to a variety of clinical information contained in their electronic health records.
Open notes are not new at the institutional level. In fact, “more than 250 healthcare organizations grant such access to more than 53 million patients,” said Dr. Catherine DesRoches in a MedPage Today interview. Among those organizations are: the Mayo Clinic, the MD Anderson Cancer Center, Sanford Health, and the U.S. Department of Veterans Affairs.
What’s new is that open notes will now be a federally mandated requirement applied to all clinicians. “Patients have had the right to see their medical record, but it hasn’t been easy, in general, for them to do that,” said Dr. DesRoches. This new ruling makes it easy and convenient for patients to gain access to their clinical records through a secure, online portal.
The “open notes” law states that patients have access to eight types of clinical notes. These notes cannot be blocked and must be made immediately available to the patient: history and physical, progress notes, consultation notes, procedure notes, discharge summaries, lab reports, imaging reports, and pathology reports. As soon as a doctor or other practitioner completes one of these notes, it becomes immediately available to the patient through their online portal.
“This law is a historic step in patient access,” says Dr. Bryan Vartabedian of Baylor College of Medicine. On his blog, Dr. Vartabedian writes, “It will forever change the way we see information and its relationship to patients.” He adds that “it’s staggering how few health professionals understand how this will impact their work.”
“I think this is going to force health professionals to help patients think about information and what they do with it,” says Dr. Vartabedian. “I suspect that the most critical ultimate change will be transparent conversations and more timely physician follow-up on high stakes studies.” Knowing that patients will pay more attention to the notes, doctors will probably have to take more time to write notes that patients can better understand.
Doctor-patient communication is likely to improve because of patient feedback regarding errors and misinformation found in the notes. Plus, patients will be in a better position to understand their doctors’ treatment plans, options, and expectations.