US experience with transparent medical records should reassure doctorsBMJ 2022; 379 doi: https://doi.org/10.1136/bmj.o2969 (Published 09 December 2022) Cite this as: BMJ 2022;379:o2969
- Catherine DesRoches, associate professor of medicine1,
- Jan Walker, associate professor of medicine1,
- Tom Delbanco, professor of medicine1
In the US, the expansion of patient access to electronic medical records over the past decade has been accompanied by numerous studies investigating the experiences of patients and clinicians. Starting from about 2000, the use of patient portals to display test results spread rapidly, and in 2010, 100 primary care doctors volunteered to open their free text entries to 10 000 of their patients. By 2019, more than 50 million patients in the US had access to what their clinicians wrote about their medical care—entries known widely as open notes.1
In 2021, the US federal government mandated that patients should have easy electronic access at no charge to all information held in their electronic health records.2 Today, patients can use readily available patient portals to access all the information a clinician might use to make decisions about their care in both inpatient and outpatient settings, including primary care and specialist notes, laboratory test results, and imaging reports.
What might doctors in the process of implementing transparent medical records learn from the US experience? Before the rollout of open notes, US clinicians expressed worries similar to those of doctors in England, who are at the start of opening up patient access to GP records.3 The experiences of US doctors provides reassurance in three areas: effects on workload, changes to documentation, and risk of litigation.
US clinicians anticipated increased workloads as patients gained access to test results and, a decade later, as they began reading their visit notes. Primary care doctors worried about upset and confused patients calling the office, sending messages, asking time consuming questions during visits, and requesting changes to what the clinician had written. These worries were largely unrealised, and at the end of the year-long 2010 pilot, none of the participating doctors chose to turn off access to notes.4 In fact, their healthcare organisations chose instead to expand access to notes written by all clinicians. These results have been replicated in hundreds of provider organisations across the country, and follow-up studies indicate that clinicians’ views of open notes become more positive over time.5
Some studies suggest that clinicians are changing the way they document in the wake of open medical records.6 In one, around 37% (292/781) of doctors reported spending at least “some” more time writing notes,7 but preliminary inquiries using the timestamps from electronic health records suggest that any increase in time spent in documentation is miniscule (fractions of a second).89 It is likely that doctors learn to think differently about how to document, particularly when new to the practice of open medical records. Such additional cognitive burden may make it feel as if they are spending more time writing, even though direct measurements of the amount of time it’s taking indicate no change. As doctors become accustomed to writing in this way, such strain may well ease.
Both in England and the US, clinicians worried initially about how transparent medical records may engender adversarial patient-clinician relationships and increase doctors’ liability. Trusting relationships are known to diminish the risk of litigation, even when errors occur, and the US’s overall experience suggests that open and transparent communication increases trust among patients, families, and clinicians.10 Moreover, the US movement to encourage disclosure and apology when problems arise provides further reassurance. Overall, studies indicate that increased transparency, disclosure, and apology may decrease the likelihood that patients and families will file lawsuits.1112 Harvard Medical School’s malpractice insurer covers 16 000 doctors practising both in neighbouring communities and at academic medical centres. In a personal communication, our insurer told us that open medical records do not seem to increase the risk that patients will allege malpractice.
Protecting vulnerable patients
Further challenges accompanying the rollout of open medical records remain. US clinicians share concerns expressed by English GPs about the wellbeing of their most vulnerable patients, such as those experiencing domestic violence or other types of interpersonal abuse.13 US regulations allow clinicians to withhold information from the patient portal if they believe it might harm an individual patient or another person.2 Yet it is unlikely that all doctors and patients are aware of this exception. Healthcare organisations, including the NHS, could help ensure the safety of such vulnerable patients by providing training to clinicians and patients. Electronic health record vendors could also design provider functions that facilitate trauma informed care, including options to create confidential notes and enhanced privacy settings that allow patients greater control over what information is available on the portal.
Another issue currently under debate in the US is when test results should be released to patients. In the past, with the expectation that clinicians would first communicate with patients, most health systems chose to delay the release of some findings, such as pathology examinations, medical imaging reports, or cardiac monitoring. In contrast, the new US rules mandate instantaneous release of virtually all results, whether or not they suggest bad news.
Challenges such as these are not insolvable, but they will take a creative combination of cultural and technical changes to resolve. All new medicines are accompanied by side effects that affect some patients adversely, and for some, fully transparent records may be contraindicated. But in the US, the benefits of open medical records for all involved seem to well outweigh the risks. Patients consistently report clinically meaningful effects, and any potentially negative effects on practitioners have been limited and manageable.
Competing interests: We have read and understood BMJ policy on declaration of interests and declare the following: JW has received a grant from the John A Hartford Foundation. CMDesR has received grants from the US Department of Health and Human Services Office of the National Coordinator for Health Information Technology, National Institute on Ageing, and National Cancer Institute; Cambia Foundation; CRICO Risk Management; John A Hartford Foundation; NYS Foundation; Patient Centered Outcomes Research Institute; R C Wilson Jr Foundation; and Swedish Ministry of Health and Foreign Affairs.
Provenance and peer review: Commissioned; not externally peer reviewed.