Powering relationships through shared therapy notes.
Information is power. Nobody knows that better than doctors and therapists. With more of the right patient information, we have the power to make better decisions about care, deliver it without delay, and create better care outcomes.
Information empowers patients, too. With their own medical records and histories in their control, sharing it is an instant experience. Patients are more engaged. Guesswork is vanquished. Therapeutic alliances are strengthened.
The 21st Century Cures Act gives the patients the legal power to request and hold their own medical records. The Act is a mandate for providers to share all records with patients upon request, therapy notes included. There’s little ambiguity in the legislation; denying such a request puts you at odds with the law. The only exceptions are for process recordings or notes that providers mark as “private.”
Sharing is caring
Of course, sharing therapy notes runs counter to the long-held notion that such information should be held private and out of sight from the patient for concern of a negative reaction. However, there’s a growing body of evidence to suggest (if not confirm) that just the opposite is true.*
For patients, sharing therapy notes takes the mystery out of what you are writing down in sessions. Transparency helps your patient feel respected and breeds confidence that the both of you are on the same page. Shared notes also present an opportunity to set the record straight should the patient discover that the two of you are not in sync. All of which prompts dialog and fosters provider/patient trust.
Of course, not all patients will feel compelled to read your therapy notes, let alone acquire their complete medical records. Still, it’s important that your patients know that the opportunity is there for the taking if they so desire. The art of the invitation itself is a potent act of transparency that can be appreciated.
What might change
Knowing that there’s always a chance that your patients will see your notes, you might think about using simpler language with fewer medical terms and abbreviations. However, don’t dismiss professional note-taking standards or requirements. On the chance that you’ve written something your patient finds difficult to understand, restate a standing offer to review your notes together and clarify uncertainties.
What will not change
Nothing in the 21st Century Cures Act dismisses you from keeping your patient information compliant with the Health Insurance and Portability and Accountability Act (HIPAA). You still need to be mindful of protecting health information, keeping patient information secure, and releasing it only to authorized individuals. Now, that list of authorized individuals includes the patient.
If it’s not already part of your routine, sharing notes with patients may feel awkward at first. But in time, it will make for smarter and more engaged patients and improve your chances for success with each one.
A brief history of sharing
The concept of sharing notes with patients is not new. The non-profit, OpenNotes, has been advocating for greater provider/patient transparency for some 50 years. HIPAA gave patient rights a big lift in 1996, and the 2022 expansion of the 21st Century Cures Act cemented patients’ legal standing regarding records acquisition and ownership.
Meanwhile, technology is providing fuel for a new era of patient-centered care in which note sharing plays a significant role. Robust online patient portals, such as that developed by MediSprout, give patients a secure and private place to access and review therapists’ notes and then store and share them (if so desired) right along with their complete medical histories. Patients can choose to read therapy notes, or not to. What’s important is that the opportunity is there.
Developing a bit slower on the technology curve are electronic health records (EHR) platforms that do a better job of exchanging patient records and information with other health systems. Tech improvements on this front are also mandated by the 21st Century Cures Act. Platforms that integrate EHR and practice management systems are leading the charge. Sharing information with speed and efficiency is critical for timely care; integrated systems offer a seamless and immediate process.
As the roots of patient-centered care grow deeper in the healthcare landscape, shared decision making—and the therapy notes that help inform those decisions—will play a more significant role. To be sure, it’s the future of healthcare. The best decisions are made when the right information is in the hands of all decision makers.
Samant Virk, MD, is the CEO and founder of MediSprout.
* Psychiatry Online: Open Notes Becomes A Law: A challenge for Mental Health Practices
0 Comments
Leave a comment