Many physicians are not comfortable sharing their progress notes with patients, concerned that they will take offense, be confused and add to the practice workload by calling or emailing with questions.
But under the Health Insurance Portability and Accountability Act (HIPAA), physicians must share their notes with patients who ask. Some physicians have embraced this sharing, encouraged by a nonprofit Boston-based initiative called OpenNotes. Their experience can serve as a guide to others who want to navigate this challenge.
A note is a much richer source of information for the patient than lab results or an algorithm-driven clinical summary, says Janice Walker, RN, MBA, a principal investigator at OpenNotes and a researcher at Boston’s Beth Israel Deaconess Medical Center. “Your labs are a series of data points, but notes, especially if you [the patient] have a chronic condition and if you read the notes over time, tell the story of how you’re doing.
The OpenNotes team of investigators, physicians and medical informatics experts works to make note sharing the norm rather than the exception. Through research and guidance, OpenNotes encourages hospitals and physician practices with electronic health record (EHR) systems to push notes onto the patient portal and automatically notify patients when the note is available.
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