We’ve discussed before the industry-wide push for patient empowerment and value-based care. And while this push is surely still happening, a recent delay in the federal “Open Notes” rule that would grant patients instant access to their clinical notes has slowed this push. 

This by no means invalidates efforts made to move to a more value-based care model, however – as several facilities have already begun embracing Open Note policies by implementing note-taking solutions such as voice scribing and the streamlining of login practices through medical computer systems. All that’s happening is a moving of deadlines. Instead of Monday, November 2nd, providers will be forced to grant access to patient notes by April 5th, 2021. This delay is an understandable one since many were more preoccupied with addressing the unexpected COVID-19 pandemic than they were with note transparency.

Despite this delay, OpenNotes – a research initiative dedicated to transparency in healthcare – as of October 2020, explains that 53 million patients have already gained access to their patient notes. And this number has only increased as many facilities ended up opening up access to their clinical notes on the original deadline of November 2nd as well. 

Delay or no, transparent “Open Notes” is happening and it’s happening soon. And if your facility is one that wasn’t prepared for the November 2nd deadline, this extension allows you some time to prepare and hit the ground running with improved care, lowered readmission rates, and more once the switch is flipped. 

Why Are Clinical Notes Being Made Transparent?

Patients are playing more of an active role in their care. With wearables, vital tracking apps, and telehealth all becoming more commonplace, keeping track of one’s health has never been more accessible for the average patient. And as patients have become more invested in their health, healthcare consumerism has started to take place, prompting many to offer fully transparent patient notes in order to meet this new demand and compete with other care facilities’ offerings. Fortunately, open notes don’t only benefit the patient.

The Benefits of Transparent Clinical Notes

It’s been well documented that increased health literacy, the kind many patients are seeking by demanding access to their clinical notes, leads to improved patient outcomes across the board. 

This only makes sense if you take a moment to consider it. A patient who understands their condition and can read exactly what their physician is paying attention to as far as symptoms, dangerous habits, etc., is more equipped to address those things. And better patient outcomes means less patient readmissions which, in addition to helping facilities avoid financial penalization, saves healthcare teams from wasting supplies, staff, and rooms on patients who could have been treated more effectively.

Of course, health literacy means patients need to actually understand the open notes they are now being granted access to and that means keeping a few new considerations in mind when going about taking and sharing these notes.

Creating Accessible Patient Notes

For those who feel they are in uncharted waters when it comes to opening up access to patient notes, the key to doing so effectively is formatting these notes in ways that can be understood by patients. That will be the only way we see the benefits of improved health literacy we mentioned earlier. 

Change the Kind of Language Used

It’s no shock to hear that healthcare is rife with complex terminology that can sometimes be hard to decipher for even trained professionals. And clinical notes that are bogged down with all of this jargon will be of no use to patients who are simply trying to manage illnesses, lower blood pressure, lose body fat, etc. In efforts to improve the comprehensibility of these patient notes, providers will need to adopt a similar approach to one used to create effective patient education materials: material needs to be written with the average patient’s reading and comprehension level in mind. The general recommendation is to write for a 7th or 8th grade reading level.

In addition to being clear and succinct, the American Journal of Medicine also recommends using more supportive language – mentioning not just problems, but even successes in a patient’s healthcare journey – in order to encourage adherence to treatment plans and discourage avoidance of reading clinical notes. They also suggest that, when having to address uncomfortable or concerning issues with a patient’s health, to be respectful, adopting a frank but caring attitude. 

Make Patient Notes Easier to Navigate

In order to make patient notes more comprehensible, there needs to be some efforts taken to improve the organization of said notes in addition to the kind of language used when writing them. 

Compartmentalized, organized note taking standards such as SOAP notes give both patients and physicians the ability to easily scroll through notes to find the exact information they need at that moment. As far as the other benefits of SOAP healthcare practices, several facilities that have embraced the note-taking procedure have also observed a notable decrease in miscommunications, improved deployment of treatment plans, and lowered patient readmission rates. All this makes soap notes a solution that can be implemented today and provide a myriad of benefits in several other regards before the April 2021 deadline for open clinical notes has even been reached.

Improve Your Cybersecurity

Now that patient notes are becoming more transparent and objectively more accessible on the whole, patients who were already skeptical about their data being stolen understandably have even more reason to be concerned. That means two  things for your facility.

Firstly, efforts to improve your security against ever-prevalent attacks need to be fortified. And secondly, your patients need to have their concerns addressed, which means you need to keep them informed on how you’re protecting their information as well. 

On the first point, improving authentication procedures for workstations that house your valuable patient notes is well-advised. Fortunately, the right medical grade tablets and medical cart computers can be customized with RFID scanners to confirm the identities of those who are accessing patient notes and EHRS. Used in conjunction with single sign on solutions, these authenticators can help create a more iron-clad defense against cyberattacks that are, unfortunately, only increasing in frequency.

In regards to keeping patients informed on these efforts, adopting a digital front door healthcare strategy that maintains multiple means of outreach can give patients multiple avenues to educate themselves on your new programs.  

Having to Prepare for More Educated Patients is a Good Thing

Having to rewrite the procedures behind how clinical notes are written, stored, and shared is invariably going to ask for a little extra work from healthcare staff. However, all of this considered, patients becoming more educated and active in their care is a good thing for all parties involved. Patients come out healthier, facilities come out with less money wasted, and healthcare staff come out feeling more fulfilled being able to provide more effective care to those they were hired to heal. For more information on the kind of hardware necessary to take a strong first step towards more transparent patient notes, contact an expert from Cybernet today.