Established in 1927 by the American College of Physicians


2 October 2012 Annals of Internal Medicine Tip Sheet

Annals of Internal Medicine is published by the American College of Physicians on the first and third Tuesday of every month. These highlights are not intended to substitute for articles as sources of information. For a copy of an article, call 215-351-2653 or e-mail Angela Collom at

1. Survey: Online Access to Doctors’ Notes Improves Patient Engagement in Care with Little Impact on Doctor Workload

Inviting patients to read their doctors’ notes improves patient engagement, understanding, and compliance in health care plans without increasing physician workload. Researchers surveyed 105 primary care physicians and 13,564 patients who had their doctors’ notes made available to them through an electronic portal during a one-year voluntary program. Of the 5,391 patients who reviewed at least one note and completed the survey, up to 87 percent reported that the open notes program made them feel more in control of their care, and up to 78 percent reported increased adherence to medications. Nearly all (99 percent) of the patients who responded felt that the program should continue, but approximately one-third expressed concerns about privacy. Initially, physicians said they feared open notes would add time to office visits and administrative tasks and could worry or offend patients. However, the doctors reported that their concerns never materialized. When asked to describe the most difficult aspect of the open notes program, 74 percent of the 104 physicians who responded said that nothing was difficult and that they experienced no changes in their practice. In an accompanying editorial, a patient who participated in the study shares that in his parents’ day, patients did not question a physician, even if information could ease suffering. In his own experience with a serious illness, the author expressed gratitude the he was empowered to increase his chances of survival through the transparency of open notes. The author writes that “passivity robs patients of a wide range of steps that they, and only they, can take toward improved well-being.”

2. Use of Electronic Health Records Improves Outcomes in Patients with Diabetes

Using electronic health records (EHR) improves health care and outcomes for diabetes patients – especially for those with poor disease control. Researchers reviewed medical records for 169,711 patients with diabetes to examine the association between use of a commercially available certified EHR and clinical care processes and disease control. Over three years between 2005 and 2008, a health care system replaced all paper medical records with the EHR at multiple outpatient practices. As each practice adopted the EHR, researchers compared outcomes in patients with diabetes before and after introduction of the EHR. The researchers found that use of the EHR improved monitoring, treatment, glucose control, and cholesterol levels among diabetes patients. According to the authors, the EHR system increases the amount and timeliness of clinical information available at the point of care with embedded decision support and order entry. Thus, patients with the greatest need experienced increased testing, treatment and physiologic improvements, while patients with the least need experienced decreased testing and treatment intensification.

3. New Equations More Accurate than Existing Methods for Estimating Kidney Function in Older Adults

Two new equations to estimate glomerular filtration rate (GFR) have proven more accurate than existing equations for assessing kidney function in older adults. The goal of the Berlin Initiative Study (BIS) was to assess kidney function in an elderly population-based cohort by comparing existing equations to a gold standard measurement (iohexol plasma clearance) and to derive a novel estimating equation that would estimate GFR more accurately in patients aged 70 and older. Kidney function for 610 elderly patients was assessed using iohexol plasma clearance. The researchers then developed two new equations to estimate GFR in elderly participants – one based on creatinine only (BSI1) and one based on both creatinine and cystatin C measurements (BSI2). Compared with current creatinine-based or creatinine- and cystatin C-based equations, the new BIS1 and BIS2 equations showed better precision and excellence agreement with measured GFR, especially in a population with CKD in stages 1 to 3. The authors conclude that the new BIS equations may provide more methods for estimating GFR in older adults.