Intended for healthcare professionals

Analysis

Commentary: Opening access to the medical record calls for other reforms

BMJ 2015; 350 doi: https://doi.org/10.1136/bmj.h271 (Published 10 February 2015) Cite this as: BMJ 2015;350:h271
  1. Victor M Montori, professor of medicine1,
  2. Claudia C Tabini, community activist2
  1. 1Knowledge and Evaluation Research (KER) Unit, Mayo Clinic, Rochester, Minnesota, USA
  2. 2Rochester, Minnesota, USA
  1. Correspondence to: V M Montori montori.victor{at}mayo.edu

The medical record has evolved from clinician notes to self and then colleagues1 into instruments for other uses, such as accountability and billing. When they became electronic, it became easier to produce longer notes. Records often contain redundant copied elements from earlier notes and irrelevant information, sometimes intended to support better reimbursement. When clinicians write, they seldom consider patients as readers and often use technical jargon and opaque expressions. Giving patients and caregivers access to bloated and complex notes seems unlikely to meet their needs. But results of yearly Mayo Clinic patient surveys are consistent with the findings reported by Walker and colleagues …

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