Access to Your Doctor’s Notes

If you took a peek at your doctor’s notes and saw: “Although he’s SOB, I see NERD.” What would you think?

Doctors’ notes, those all-important words a physician writes during a medical exam, have traditionally been hidden from the patient. Now an initiative is under way to remove that veil of secrecy. A study called OpenNotes is testing whether allowing patients online access to their doctor’s notes will help or hurt the doctor-patient relationship.

The 12-month trial involves more than 100 primary care physicians and 25,000 of their patients at Boston’s Beth Israel Deaconess Medical Center, the Geisinger Health System in Danville, Pa., and Seattle’s Harborview Medical Center. These facilities all use electronic records and have created a secure website where patients can access their records.

A preliminary report on the risks and rewards of peering into a doctor’s thoughts was published online in the July 20 issue of the Annals of Internal Medicine.

“While some patients were nervous about learning something they didn’t know about their health or about what the doctor really thinks of them, most were very intrigued,” says co-investigator Jan Walker of Beth Israel Deaconess Medical Center. “They definitely saw an advantage to being able to look at the notes and refresh their memory of what was said during the appointment.”

For doctors, the big concern is the additional time it might take, not only to field follow-up queries from patients, but also to write notes without jargon or shorthand. For example, SOB means “shortness of breath” and NERD stands for “no evidence of recurrent disease.”

“I am looking forward to seeing whether there truly is incremental value to making available to patients online the actual text of the doctor’s note beyond the diagnoses, medications, orders, instructions,” says Larry Garber, M.D., medical director for informatics at the Fallon Clinic in Worcester, Mass.

People can share their own feelings about sharing doctors’ notes in a brief survey available on the Annals website.

The project is supported by a grant from the Robert Wood Johnson Foundation.

Cathie Gandel is a freelance writer based in Bridgehampton, N.Y.