Amend Notes as the Next Frontier of the Open Notes Movement

In the name of promoting transparency and patient autonomy, the open notes provision of the 21st Century Cures Act has mandated patients receive easy and immediate access to information in their electronic health record (EHR). To further these aims, I present a framework for active patient participation in their charting through patients proposing amendments to select EHR sections post-visit. Patients already contribute to ensuring the accuracy of their health information by completing screening questionnaires that may include things like family history, social history, or symptom-oriented surveys prior to intakes or follow-up visits. Therefore, proactively creating space for patient feedback post-visit to sections of their EHR advances transparency and patient autonomy through routes with established precedent. Proposed sections include the patient social history, treatment plan, and an open comment section.
Cultural humility acknowledges that people cannot understand all cultures. Culture influences and shapes social history, so an opportunity for patient-initiated amendments would create additional space for patients to write their history in their own words while clarifying misunderstandings. Treatment plans are best when done in partnership with patients. Post-visit edits would promote this partnership while creating an avenue for providers to receive important information on patient understanding of their treatment plan. Finally, an optional open comment section can catch remaining concerns. Open notes seeks to promote patient autonomy through increasing transparency in health care. Empowering patients to comment on their EHR can help them to clarify information in their own language, increasing investment in their care to create better outcomes.

Jeffrey Zabinski – Department of Psychiatry – Columbia University Irving Medical Center