Increase clinical note transparency through OpenNotes.

Adopting OpenNotes: Partnering with Patients

  • Hannah Chimowitz, BA OpenNotes
  • Kelly Lawman OpenNotes
  • Catherine DesRoches, MPH, PhD OpenNotes
CME Credits: 0.5
Adopting OpenNotes: Partnering with Patients

How will this module help me successfully adopt OpenNotes?

  1. Outlines six steps for increasing transparency by adopting OpenNotes
  2. Presents evidence to support the case for using OpenNotes in your practice
  3. Shares resources to help you learn how to write transparently and help clinicians, patients and caregivers make the most of shared notes
  4. Provides case studies and examples from early adopters of OpenNotes

CME accreditation information 

Increasing administrative responsibilities—due to regulatory pressures and evolving payment and care delivery models—reduce the amount of time physicians spend delivering direct patient care. OpenNotes is a national initiative working to give patients easy access to their health care visit notes. This module will outline the concept of sharing visit notes with your patients, step-by-step strategies in adopting OpenNotes, as well as tips for physicians and the entire care team to maximize the benefits of OpenNotes.

Clinical Decision Support and Diagnostic Imaging
Release Date: May 2017
End Date: May 2020

Objectives

At the end of this activity, participants will be able to:

  1. At the end of this activity, learners will be able to prepare the practice and patients on how to increase transparency of physician notes using OpenNotes.
  2. At the end of this activity, learners will be able to provide evidence to support the case for OpenNotes in your practice.
  3. At the end of this activity, the physician will be able to demonstrate clear note taking techniques that patients are likely to better understand.

Target Audience

This activity is designed to meet the educational needs of practicing physicians, other clinicians and practice managers may also be interested in this activity.

Statement of Competency

This activity is designed to address the following ABMS/ACGME competencies: practice-based learning and improvement, interpersonal and communications skills, professionalism, systems-based practice and also address interdisciplinary teamwork and quality improvement.

Accreditation Statement

The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

Credit Designation Statement

The American Medical Association designates this enduring material for a maximum of 0.5 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Claiming Your CME Credit

To claim AMA PRA Category 1 Credit™, you must 1) view the module content in its entirety, 2) successfully complete the quiz answering 4 out of 5 questions correctly and 3) complete the evaluation.

Planning Committee

  • Alejandro Aparicio, MD, CME Program Committee Advisor, AMA
  • Marie T. Brown, MD, FACP, PS2 Senior Physician Advisor, AMA
  • Bernadette Lim, Program Administrator, AMA
  • Lisa Lipinski, Manager, Physician Education Resources, AMA
  • Stacy Lloyd, MPH, Senior Practice Development Specialist, AMA
  • Christine A. Sinsky, MD, FACP, Vice President, Professional Satisfaction, AMA

Author(s)

  • Hannah Chimowitz, BA, Clinical Research Assistant II, OpenNotes
  • Kelly Lawman, Director of Communications, OpenNotes
  • Catherine DesRoches, MPH, PhD, Executive Director, OpenNotes

Faculty

  • John Santa, MD, MPH, Director Dissemination, OpenNotes, Beth Israel Deaconess Medical Center
  • Eileen Whalen, MHA, RN, President and COO, The University of Vermont Medical Center

About the Professional Satisfaction, Practice Sustainability Group

The AMA Professional Satisfaction and Practice Sustainability group has been tasked with developing and promoting innovative strategies that create sustainable practices. Leveraging findings from the 2013 AMA/RAND Health study, "Factors affecting physician professional satisfaction and their implications for patient care, health systems and health policy," and other research sources, the group developed a series of practice transformation strategies. Each has the potential to reduce or eliminate inefficiency in broader office-based physician practices and improve health outcomes, increase operational productivity and reduce health care costs.

Disclosure Statement

The content of this activity does not relate to any product of a commercial interest as defined by the ACCME; therefore, neither the planners nor the faculty have relevant financial relationships to disclose.

Media Types

This activity is available to learners through Internet and Print.

Hardware/software Requirements

Adobe Flash 9.0.115 or above
Audio speakers or headphones
Screen resolution of 800X600 or higher
MS Internet Explorer 8.0 or higher, Firefox, Opera, Safari, etc.
Adobe Reader 5.0 or higher

The project described was supported by Funding Opportunity Number CMS-1L1-15-002 from the U.S. Department of Health & Human Services, Centers for Medicare & Medicaid Services. The contents provided are solely the responsibility of the authors and do not necessarily represent the official views of HHS or any of its agencies.

References

  1. Bell SK, Mejilla R, Anselmo M, et al. When doctors share visit notes with patients: a study of patient and doctor perceptions of documentation errors, safety opportunities and the patient-doctor relationship. BMJ Qual Saf. 2016. doi: 10.1136/bmjqs-2015-004697. [Epub ahead of print] http://qualitysafety.bmj.com/content/early/2016/05/26/bmjqs-2015-004697.long.
  2. Delbanco T, Walker J, Bell SK, et al. Inviting patients to read their doctors' notes: a quasi-experimental study and a look ahead. Ann Intern Med. 2012;157(7):461-470. http://annals.org/aim/article/1363511/inviting-patients-read-doctors-notes-quasi-experimental-study-look-ahead.
  3. Delbanco T, Walker J, Darer JD, et al. Open notes: doctors and patients signing on. Ann Intern Med. 2010;153(2):121-125. http://annals.org/article.aspx?articleid=745909.
  4. Dobscha SK, Denneson LM, Jacobson LE, Williams HB, Cromer R, Woods S. VA mental health clinician experiences and attitudes toward OpenNotes. Gen Hosp Psychiatry. 2016;38:89-93. http://www.ghpjournal.com/article/S0163-8343(15)00191-7/abstract.
  5. Esch T, Mejilla R, Anselmo M, et al. Engaging patients through OpenNotes: an evaluation using mixed methods. BMJ Open. 2016;6(1):e010034. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4735137/.
  6. Feldman HJ, Walker J, Delbanco T. OpenNotes: hospitalists' challenge and opportunity. J Hosp Med. 2013;8(7):414-417. http://onlinelibrary.wiley.com/doi/10.1002/jhm.2052/abstract;jsessionid=C09430E113D7C0789BF0FC748E0FC323.f01t01.
  7. Klein JW, Jackson SL, Bell SK, et al. Your patient is now reading your note: opportunities, problems and prospects. Am J Med. 2016;129(10):1018-1021. http://www.amjmed.com/article/S0002-9343(16)30548-4/abstract.
  8. Leveille SG, Walker J, Ralston JD, Ross SE, Elmore JG, Delbanco T. Evaluating the impact of patients' online access to doctors' visit notes: designing and executing the OpenNotes project. BMC Med Inform Decis Mak. 2012;12:32. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3351950/.
  9. Meltsner M. A patient's view of OpenNotes. Ann Intern Med. 2012;157(7):523-524. http://annals.org/article.aspx?articleid=1363515.
  10. MyHealth: Open Notes FAQs. Stanford Health Care. Accessed August 16, 2016.
  11. Nazi KM, Turvey CL, Klein DM, Hogan TP, Woods SS. VA OpenNotes: exploring the experiences of early patient adopters with access to clinical notes. J Am Med Inform Assoc. 2015;22(2):380-389. https://academic.oup.com/jamia/article-lookup/doi/10.1136/amiajnl-2014-003144.
  12. OpenNotes website. Accessed August 16, 2016.
  13. OpenNotes research. Accessed April 3, 2017.
  14. Vodicka E, Mejilla R, Leveille SG, et al. Online access to doctors' notes: patient concerns about privacy. J Med Internet Res. 2013;15(9):e208. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3785972/.
  15. Walker J. The rise of the patient voice. OpenNotes website. Published August 4, 2016. Accessed August 16, 2016.
  16. Wolff JL, Darer JD, Berger A, et al. Inviting patients and care partners to read doctors' notes: OpenNotes and shared access to electronic medical records. J Am Med Inform Assoc. 2016. doi: 10.1093/jamia/ocw108. [Epub ahead of print] http://jamia.oxfordjournals.org/content/early/2016/07/24/jamia.ocw108.
  17. Wright E, Darer J, Tang X, et al. Sharing physician notes through an electronic portal is associated with improved medication adherence: quasi-experimental study. J Med Internet Res. 2015;17(10):e226. http://www.jmir.org/2015/10/e226/.

Introduction

Allowing patients to access information in their medical records can improve the relationship between physicians and their patients. While most practices agree with this viewpoint, they often struggle with how to go about increasing transparency. OpenNotes is an approach that many practices have used successfully to do just that.

OpenNotes is a national initiative working to give patients easy access to their health care visit notes. OpenNotes is not a software package or product, but rather a simple change in how your practice uses its patient portal that's been shown to promote patient engagement and enhance the patient-physician relationship.

The initiative began in 2010 when over 100 primary care physicians across three large medical institutions began sharing notes with their patients. Today, over 70 health systems have adopted OpenNotes and more than 12 million patients can access their notes online. This free process works through existing electronic health record (EHR) and patient portal platforms.

Patients, administrators and everyone on the care team has a role in making patient access to their clinician notes a routine part of health care. This module will outline how the concept of sharing visit notes with your patients can be achieved through OpenNotes. Step-by-step strategies are outlined to guide you in adopting OpenNotes, as well as tips for physicians and the entire care team to maximize the benefits of OpenNotes.

patient access to their medical record
  • What are OpenNotes? How does OpenNotes differ from a typical clinician note?

    There's no difference! The notes that OpenNotes refers to are simply everyday clinician notes made easily available to patients. For many practices, this means notes become accessible through their organization's EHR/patient portal. There's no separate template for this — it simply involves "flipping the switch" and letting patients view notes signed by clinicians, in much the same way lab reports, X-rays and other test results are increasingly being made available to patients online. For those without an EHR or patient portal, printed copies of notes can be shared. Currently, research on OpenNotes and implementation reports have only focused on ambulatory notes, though there are plans to expand OpenNotes into inpatient notes as well.

  • Is the confidential relationship between patients and clinicians different when using OpenNotes?

    No. The relationship remains confidential. Since notes are shared primarily through patient portals, OpenNotes utilizes the security measures already in place on an organization's portal system. The patient will have access to their notes, however, and may choose to share them with whomever they want.

The value of increasing patient access to their clinic notes through OpenNotes

A study published in the Annals of Internal Medicine looking at the effect on physicians and patients of facilitating patient access to visit notes through OpenNotes2 found that:

  • More than 90 percent of physicians reported that they did not need more time to address patients' questions outside of visits.
  • Approximately 80 percent of physicians reported taking the same amount or less time to write notes.
  • Approximately 90 percent of patients opened their notes made available through OpenNotes.
  • Two-thirds of patients reported doing better with taking medications as prescribed because of OpenNotes.
  • More than 75 percent of patients reported that OpenNotes helped them feel more in control of their care.
  • Nearly 90 percent of patients agreed that the availability of OpenNotes would be an important factor in choosing a future doctor or health plan.
  • Ninety-nine percent of patients and more than three-quarters of physicians wanted OpenNotes to continue.
  • How can sharing visit notes affect patient safety?

    Initial results from an ongoing patient safety research project, known as the OpenNotes Patient Safety Initiative, suggest that sharing visit notes could improve patient safety by:

    • Helping patients remember recommended tests and procedures, thus preventing diagnostic delays.
    • Encouraging patients to speak up when they have questions about symptoms, tests or treatment plans. This is especially beneficial for patients whose symptoms do not improve with treatment or patients whose symptoms persist despite negative or inconclusive test results.
    • Involving informal caregivers, giving them access to information that can help reconcile multiple treatment plans and recommended laboratory tests for chronically ill patients.
    • Enhancing trust between the physician and patient, leading to less "doctor-hopping" or fragmented care that can result in delayed diagnosis.13
    • Detecting and correcting errors earlier than current approaches.1

    Read more benefits on the OpenNotes website.

Six STEPS to increasing patient access to clinical notes through OpenNotes

  1. Educate your practice about clinical note transparency and OpenNotes
  2. Plan what OpenNotes will look like in your practice
  3. Prepare your practice and patients
  4. Adapt your documentation style as needed
  5. Learn to handle challenging topics in an OpenNotes environment
  6. Collect patient and clinician feedback about OpenNotes to refine your approach
  1. 1

    Educate your practice about clinical note transparency and OpenNotes

    Describe and share research on the many potential benefits to both patients and physicians of giving patients access to their visit notes. In particular, share research that has shown that patients who have access to their visit notes report that they:

    • Feel more in control of their health care
    • Have a better understanding of their medical conditions
    • Are more likely to adhere to their medications

    The research also showed that physicians and other clinicians who shared their notes saw:

    • Improvements in patient satisfaction, safety, communication and education
    • Improvements in the patient-physician relationship, including enhanced trust, transparency, communication and shared decision making
    • Patients better prepared for their clinic visits and becoming more actively involved in their care

    Communicate the benefits of OpenNotes to relevant stakeholders in your organization such as practice leadership, your colleagues, staff and patient advocacy groups and/or patient family and advisory councils.

  • Does using OpenNotes impact office workflows?

    There is no evidence of an impact on workflows and physicians are not reporting increased workloads. In fact, many physicians involved in the OpenNotes pilot study were surprised by how little effect the intervention had on their practice workflows. One study found that less than five percent of physicians reported longer visits, with less than 8 percent saying they spent more time addressing patients' questions outside of visits.16 The volume of phone messages and email communication from patients also did not change after OpenNotes was adopted. Some physicians did acknowledge that they took more time to write notes, and many reported writing better and more educational notes.

    The most positive impact reported related to the efficiency of the visit. There have been many reports of patients coming to visits better prepared and remembering the care plan between visits with OpenNotes.

  • Will patients be worried or confused by reading their notes?

    During initial rollouts of OpenNotes, many clinicians were concerned that patients wouldn't understand or would misinterpret the information in their notes. However, these concerns have not been evidenced, and other feedback indicates that most patients appreciate the window into what their clinician is thinking. In one analysis, 97 percent of patients understood their notes with little difficulty.1 It's important for clinicians to let patients know that any points of confusion regarding the visit notes can be clarified at the next visit or the patient can ask for help right away if confusion about the notes might impact their treatment.

  1. 2

    Plan what OpenNotes will look like in your practice

    When implementing OpenNotes, it is important to take into account policy considerations that your practice or organization may have. Issues such as which clinicians or departments will share notes, how to introduce patients to OpenNotes, how proxies will access patient notes and how patient requests to change notes will be handled all need to be addressed prior to rollout. Other considerations include whether individual notes can be hidden by clinicians and whether any notes will be shared retroactively. Outline team member responsibilities regarding OpenNotes, such as who will educate patients on registering for the patient portal and how to find their notes within the portal. For those who have an EHR, it is important to work with your vendor to identify any IT needs for implementation, roll out and optimization of the interface for patients and caregivers.

  • Can OpenNotes be used with any EHR?

    While all EHRs capture notes, some have not yet implemented the technical capacity to easily share notes online with patients. As of November 2016, several EHR vendors do have the capacity to provide note access through an organization's patient portal. Be sure to check with your EHR vendor to see if they have this capacity. Other vendors are anticipated to have this capacity in the future and in the meantime, all physicians can still print out their notes for patients.

  • Can I participate in OpenNotes without a patient portal?

    There are many clinicians who have widely shared visit notes with their patients throughout their careers, decades before EHR or online portal technology was available. Though most practices who use OpenNotes share notes electronically through their patient portal, there are several options that may better suit your practice's workflow. Remember that you don't need specialized technology to take advantage of OpenNotes. You may consider sharing the visit notes with patients as a printout that is stapled to the after-visit summary or handed to them as they leave the exam room. This is a convenient option if your practice layout includes a printer located in or near the exam rooms. Printing notes is also helpful for patients who may not be able to access them via computer.

  • Can OpenNotes be used by any specialty?

    Yes. Some specialties, particularly those in which significant patient follow-up is required, could benefit greatly from OpenNotes. Patients can use the notes to understand and share follow-up care recommendations, including physical therapy guidance, referrals and upcoming labs. OpenNotes may also be especially beneficial for patients with complex chronic conditions who are managed across specialties, for patients with impaired cognitive function who see a specialist and those with care partners.

  • What types of notes should be shared?

    Most practices share ambulatory visit notes. While only a few sites are sharing inpatient notes, many provide online access to discharge summaries as a step in that direction. If you are awaiting lab results that will inform your treatment plan, you may consider delaying the release of some visit notes. For example, you may choose to embargo some notes or other health information until you are able to have a phone conversation or follow-up visit with the patient. Practices often delay the release of notes that contain abnormal results so they can be discussed before they are made available to the patient.

  • What are the roles of individual care team members in making OpenNotes work?

    All team members should be aware that the practice is participating in OpenNotes. This means they should have enough understanding to explain the concept and set expectations with patients about where and when they will see their notes. Medical assistants, health coaches and/or front desk staff can assist patients with registering for the patient portal or locating their note once they are registered and logged in.

  • What kind of protective policies should I put in place as we begin to use OpenNotes?

    Depending on the EHR and specific policies within a certain practice, some organizations offer clinicians the option to 'hide' certain visit notes. Even though research suggests that less than one percent of OpenNotes participants use this option, it still may provide some peace of mind. Some practices also choose to initially exclude certain patients from OpenNotes. For example, the obstetrics/gynecology department at BIDMC decided that the family planning group and its patients would not participate in OpenNotes because of the sensitive nature of these visits and concern about consequences if this information was inadvertently shared. Clinicians may also hide a particular note from a patient in situations where issues need to be discussed in person first.

Improve transparency with OpenNotes #STEPSforward

  1. 3

    Prepare your practice and patients

    As with anything new, you may encounter some initial resistance internally when adopting OpenNotes. Prepare your practice and potentially decrease pushback by raising awareness. Discuss the importance of transparency and answer questions about OpenNotes in team meetings, educate team members and patients on the benefits of OpenNotes, and encourage practice-wide participation in implementing the new approach. There are also many opportunities to network and learn about best practices from other organizations and physicians who have already implemented OpenNotes. For example, clinicians at the Mayo Clinic have been sharing all visit notes with patients since 2013.

    The more you can prepare everyone involved about the adoption of OpenNotes, the easier the transition will be. Help prepare your patients, team members and all stakeholders by raising awareness. The following are some suggestions for doing so.

    To prepare clinicians and practice staff:

    • Describe and share research on the many potential benefits during team meetings.
    • Distribute clinician-specific FAQs.
    • Provide department leaders and/or your organization's CEO with a template email they can send to staff.
    • Post information about adopting OpenNotes on your practice or organization staff intranet site.

    To prepare patients and caregivers:

    • Send an email introducing OpenNotes and how it will impact them.
    • Make patient-specific FAQs available in all waiting rooms, in exam rooms, on your patient portal and wherever else your patients may easily access them.
    • Post information about adopting OpenNotes on your practice or organization website and patient portal.
    • Promote the adoption of OpenNotes through your practices' and/or organizations' marketing channels such as a practice newsletter, or on Facebook and Twitter.

    As your practice gains more experience with OpenNotes, help spread the word and continue to engage your stakeholders by:

    • Collecting stories from patients and clinicians in your practice who are using OpenNotes and share them through your practices' and/or organizations' marketing channels such as a practice newsletter, or your website.
    • Asking patients and clinicians to blog about their experiences with OpenNotes.
    • Committing to track OpenNotes utilization by both patients and clinicians so you can regularly update stakeholders with the findings.
    • Adding questions about OpenNotes to your patient satisfaction survey.
  • What are some common concerns clinicians have about OpenNotes and how can we be proactive about addressing them?

    The two most common concerns among clinicians are that increasing patient access to their visit notes will require more time and that patients will be upset as a result of reading their notes. It can be helpful to distribute information about OpenNotes to your team, including how few patients report becoming upset and how little impact OpenNotes has had on clinicians' time, as well as tips to minimize challenges. Behavioral health clinicians and those caring for adolescents may be especially worried about increased patient access to notes because of privacy concerns, but many organizations have implemented OpenNotes successfully despite these initial worries.

  • How should I prepare patients for OpenNotes?

    Explain what OpenNotes is and why you are moving to this more transparent method of sharing information about their visit. Describe what visit notes are and what they can expect to see in them. Inform patients that, although the portal will make notes available, it is their choice to decide if they want to read their notes. Depending on the type of EHR your practice uses, you may be able to create an automatic reminder system so patients know to review their notes before their next visit. Reminders are proven to increase note reading rates.

  • Can caregivers, family members or proxies access a patient's visit notes?

    It's not uncommon for patients with chronic or complex illnesses to want to share their medical information. Patient safety and confidentiality is paramount and there are protective measures you can take to minimize privacy concerns. First, have a process in place for patients to privately and securely grant access to their records and visit notes to another person of their choosing. Procedures for signing up for proxy access vary across organizations. If your practice has a patient portal, you may have already dealt with this question. Second, if your patient portal allows, let patients know they may have the opportunity to decide which notes can be viewed. Lastly, let patients know that they can retract viewing privileges from a proxy or caregiver at any time.

  • Are patients charged for accessing their notes like they are for a medical record?

    No. Opening notes should be available to patients at no cost. No organization currently using OpenNotes charges for them.

  1. 4

    Adapt your documentation style as needed

    Just because patients will now be able to view the note, that doesn't mean that you or your team need to make dramatic changes to your writing style. In fact, most physicians won't need to make any changes to their speaking or writing style. Convey the need for mindfulness when communicating with patients (either verbal or in written communications) to medical assistants, nurses and anyone else on the team who contributes to team documentation. General communication strategies include:

    • Speaking or writing only about things discussed with the patient during that visit
    • Not including commentary that could be interpreted as labeling or judgmental
    • Being positive and supportive
    • Avoiding use of medical jargon, acronyms and abbreviations. Not only does this create confusion, but some terms may unintentionally offend patients if they don't know what it means. For example, SOB is commonly used as an abbreviation for shortness of breath that could be misinterpreted as a derogatory remark
  1. 5

    Learn to handle challenging topics in an OpenNotes environment

    Long before the OpenNotes initiative, clinicians worried about how to document challenging topics such as mental health, obesity, substance use, physical abuse, driving privileges, visits with potentially litigious patients or suspicions of life-threatening illness. Sensitive issues clearly require special attention.

    Although it is natural to want to curb or avoid some challenging conversations, patients may benefit from direct dialogue. For example, when a clinician notices signs of dementia, depression or impaired driving, chances are that the patient or family members are already worrying about these issues as well. They may find that a balanced discussion helps alleviate their anxiety.

  • What are some things I should consider when drafting a note about a challenging topic? I'm worried some patients may become scared or angry after they read a visit note and not sure how to prevent that.

    The best approach in many situations is to discuss everything you are putting in the visit notes with the patient. Use the same words in conversation that will appear in the notes. Many clinicians already follow this practice and some dictate notes with their patients present. Also, be direct and respectful when addressing concerns with the patient. Document your discussion using supportive language.7 You could also 'monitor' notes if this functionality is allowed through your EHR vendor.

    Certain conditions will require more patient education and reassurance. For example, a patient may become upset when they see something in their notes, such as "chronic kidney disease stage 3." Be prepared for these concerns, especially if they are common, by providing patient education along with the notes and ensuring that your team is able to respond to the patient's questions.

    If you believe that accessing a specific note will upset or harm a patient, you could decide to make that note “private” if your EHR has this option. The note will remain part of the patient's medical record and will be available to them if they ever request their complete file. Remember that HIPAA entitles patients to obtain copies of their complete medical records. Independent of OpenNotes, it is best to write notes with the understanding that patients may read them. If you're uncertain about security or a patient becoming combative about what is documented, contact a supervisor or risk management officer at your organization before sharing the notes.

  • Does it take longer to draft a transparent note on a sensitive issue?

    In the initial OpenNotes study, only a few clinicians reported changing the way that their notes addressed these topics. This ultimately did not result in more time preparing their notes, but they found themselves using different language as they were drafting the notes.

  • What are the benefits of using transparent notes to address sensitive health issues?

    Clinicians in the OpenNotes study found that when some patients read visit notes about obesity or substance abuse, they were more motivated to attempt difficult behavioral changes. Some patients reported that “seeing it in black and white” made it more real. As an overarching strategy, promoting transparency may encourage more open and active communication in these challenging areas.

  1. 6

    Collect patient and clinician feedback about OpenNotes to refine your approach

    To fully understand the impact OpenNotes is having on your practice, measure the process from start to finish - establish a baseline, a midpoint and an endpoint for your OpenNotes initiative. You can collect information on the use of and perspectives about OpenNotes through informal hallway conversations, at team meetings and by adding questions about OpenNotes to your patient satisfaction survey. Another option is to track the volume of patient emails and phone calls before and after OpenNotes as an indirect measure of the effect of OpenNotes on time spent by clinicians fielding patient questions. Work with your EHR vendor or IT team to quantify how many patients view their notes via the patient portal.

  • Have organizations witnessed an uptick in requests for changes to the medical record after implementation of OpenNotes, and how is this tracked?

    Anecdotal evidence suggests that organizations currently using OpenNotes are not seeing an increase in the number of requests for changes to the medical record. Requests for changes typically come from the same patients who were asking for them before the use of OpenNotes.

  • How long does it take for OpenNotes to become routine?

    It varies but it usually doesn't take long. Most practices are surprised by how much of a non-event transitioning to OpenNotes is. The longest implementation process tends to be experienced by organizations who adopt an 'opt-in' approach where only select clinicians or departments are participating.

  • What does the future of OpenNotes look like?

    Practices are encouraged to innovate and tailor how they use OpenNotes to increase patient involvement in collaborative care. As you explore new features and functionality for your patient portal, consider ways that you can make it easier for patients to contribute to their medical records and visit notes. Some ideas for engaging patients include:

    • Equipping patients to upload home measurements, such as blood pressure and glucose readings
    • Enabling patients to update or correct family and social histories in their own words
    • Sending automatic email reminders when a new note is signed and ready to read

Other physicians who are experienced with OpenNotes are excited by finding new ways in which their patients can obtain their health information easily. They encourage patients to register for the patient portal, describing it as an extension of their practice. These physicians also encourage their patients to ask questions through email and text.

Partner with your patients to improve care #STEPSforward

Conclusion

OpenNotes is a method to engage patients and increase transparency by sharing clinician notes with patients. Sharing notes can empower patients to be more active participants in their care, making them more likely to follow through on treatment recommendations. OpenNotes usually does not require additional clinician time or effort during a visit to have a positive impact on a practice and its patients.

Although studies are underway nationally, there is still much to learn about eliciting and responding to patient preferences and understanding how documentation affects desired health outcomes. In the meantime, sharing stories about OpenNotes (good and bad) in appropriate settings, and incorporating such experiences in case discussions, conferences and team meetings will bolster the collective wisdom and skill in writing transparent notes over time. You may find it helpful to regroup as a team after completing this module to share your experience.

sharing clinician notes with patients through OpenNotes

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The project described was supported by Funding Opportunity Number CMS-1L1-15-002 from the U.S. Department of Health & Human Services, Centers for Medicare & Medicaid Services. The contents provided are solely the responsibility of the authors and do not necessarily represent the official views of HHS or any of its agencies.

References

  1. Bell SK, Mejilla R, Anselmo M, et al. When doctors share visit notes with patients: a study of patient and doctor perceptions of documentation errors, safety opportunities and the patient-doctor relationship. BMJ Qual Saf. 2016. doi: 10.1136/bmjqs-2015-004697. [Epub ahead of print] http://qualitysafety.bmj.com/content/early/2016/05/26/bmjqs-2015-004697.long.
  2. Delbanco T, Walker J, Bell SK, et al. Inviting patients to read their doctors' notes: a quasi-experimental study and a look ahead. Ann Intern Med. 2012;157(7):461-470. http://annals.org/aim/article/1363511/inviting-patients-read-doctors-notes-quasi-experimental-study-look-ahead.
  3. Delbanco T, Walker J, Darer JD, et al. Open notes: doctors and patients signing on. Ann Intern Med. 2010;153(2):121-125. http://annals.org/article.aspx?articleid=745909.
  4. Dobscha SK, Denneson LM, Jacobson LE, Williams HB, Cromer R, Woods S. VA mental health clinician experiences and attitudes toward OpenNotes. Gen Hosp Psychiatry. 2016;38:89-93. http://www.ghpjournal.com/article/S0163-8343(15)00191-7/abstract.
  5. Esch T, Mejilla R, Anselmo M, et al. Engaging patients through OpenNotes: an evaluation using mixed methods. BMJ Open. 2016;6(1):e010034. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4735137/.
  6. Feldman HJ, Walker J, Delbanco T. OpenNotes: hospitalists' challenge and opportunity. J Hosp Med. 2013;8(7):414-417. http://onlinelibrary.wiley.com/doi/10.1002/jhm.2052/abstract;jsessionid=C09430E113D7C0789BF0FC748E0FC323.f01t01.
  7. Klein JW, Jackson SL, Bell SK, et al. Your patient is now reading your note: opportunities, problems and prospects. Am J Med. 2016;129(10):1018-1021. http://www.amjmed.com/article/S0002-9343(16)30548-4/abstract.
  8. Leveille SG, Walker J, Ralston JD, Ross SE, Elmore JG, Delbanco T. Evaluating the impact of patients' online access to doctors' visit notes: designing and executing the OpenNotes project. BMC Med Inform Decis Mak. 2012;12:32. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3351950/.
  9. Meltsner M. A patient's view of OpenNotes. Ann Intern Med. 2012;157(7):523-524. http://annals.org/article.aspx?articleid=1363515.
  10. MyHealth: Open Notes FAQs. Stanford Health Care. Accessed August 16, 2016.
  11. Nazi KM, Turvey CL, Klein DM, Hogan TP, Woods SS. VA OpenNotes: exploring the experiences of early patient adopters with access to clinical notes. J Am Med Inform Assoc. 2015;22(2):380-389. https://academic.oup.com/jamia/article-lookup/doi/10.1136/amiajnl-2014-003144.
  12. OpenNotes website. Accessed August 16, 2016.
  13. OpenNotes research. Accessed April 3, 2017.
  14. Vodicka E, Mejilla R, Leveille SG, et al. Online access to doctors' notes: patient concerns about privacy. J Med Internet Res. 2013;15(9):e208. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3785972/.
  15. Walker J. The rise of the patient voice. OpenNotes website. Published August 4, 2016. Accessed August 16, 2016.
  16. Wolff JL, Darer JD, Berger A, et al. Inviting patients and care partners to read doctors' notes: OpenNotes and shared access to electronic medical records. J Am Med Inform Assoc. 2016. doi: 10.1093/jamia/ocw108. [Epub ahead of print] http://jamia.oxfordjournals.org/content/early/2016/07/24/jamia.ocw108.
  17. Wright E, Darer J, Tang X, et al. Sharing physician notes through an electronic portal is associated with improved medication adherence: quasi-experimental study. J Med Internet Res. 2015;17(10):e226. http://www.jmir.org/2015/10/e226/.

STEPS in practice

Case 1

How’s it working in Sioux Falls, SD?

Avera Health is a fully integrated, faith-based health system that includes more than 800 providers in 60 specialties, covering a five-state region. Avera instituted OpenNotes in March of 2014, at the same time they activated their patient portal in MEDITECH, with little fanfare.

Patients and their families, as well as family members and neighbors of Avera providers, were informally polled about transparent medical information and their responses helped guide the decision to adopt OpenNotes. They were asked “What medical information would you want to have access to?” The overwhelming response was “Everything.”

Before the implementation of OpenNotes, patients were able to access their medical information only after submitting a request form to the clinic that indicated in detail what information they wanted. While there was no charge to the patient to access their information, it took the clinic time and effort to select, print and mail the requested materials. With OpenNotes, patients can now log into the portal at their convenience and view almost all of their ambulatory and inpatient information, including progress notes, inpatient history and physicals, consult reports and discharge summaries. Some types of notes are currently not available; for example, pathology reports turned out to be difficult to format in a way that would be useful and understandable for patients, so these are not accessible through the portal. Hospital rounding notes, operative reports, and acute vitals are also not shared through OpenNotes, primarily because providers felt patients would be overwhelmed by the sheer volume of information that often accompanies an inpatient stay. Documentation from allied health professionals, such as occupational and physical therapists, are also not shared through the portal. At this time, access to behavioral health notes is restricted. Avera has also created a “confidential note” that is valuable in circumstances where a proxy user has been established but the patient desires privacy.

Initial resistance to OpenNotes among providers was minimal. The main concern was that there would be “too many questions if the patient reads the notes.” Providers were concerned that patients might misunderstand content in the notes and this lack of understanding would have consequences for patient care. For example, they didn't want a patient to be upset if they saw the word “obesity” in their notes. Providers also worried that patients might be needlessly alarmed by their lab results or X-rays. Thus far, there have been no complaints from patients related to these initial concerns.

At the OpenNotes launch, Avera placed handouts in waiting rooms and sent messages via email to patients to raise awareness of the new service. Providers were alerted to the roll out in town hall meetings, staff emails and conversations with leadership.

Because many Avera physicians were already providing copies of their notes to their patients, it was not necessary to provide formal training on writing transparent notes. Although providers cannot opt out of using OpenNotes, their notes are not available in the portal until they are signed. This gives the provider the ability to temporarily delay a note from reaching the portal if any editing is needed.

To date, approximately 100,000 patients have accessed their medical information through the portal. Patients have not raised concerns about using OpenNotes. In several instances, patients who were reading their notes identified discrepancies, such as surgeries that they'd never had but had been reported in their histories. Their care team was able to quickly correct these errors. Although these situations can be awkward, conversations about errors in OpenNotes typically end well because both patients and providers believe that better information equals better care. Adult children of aging parents have been particularly positive about OpenNotes. If a son or daughter is not able to attend a visit with their parent, they can still easily obtain information about the visit and the care plan through proxy access. Anecdotal evidence suggests that this results in better adherence to instructions.

“Every piece of information regarding our patients belongs to them. Why shouldn't they have access to it?” says Kim Jundt, MD, Chief Medical Information Officer at Avera and a practicing family medicine physician. “We have gradually allowed access to a large amount of information and this has gone unnoticed by the majority of providers. Patients having access to their information is just a normal part of our daily process that we now take for granted.”

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Case 2

How’s it working in Boston, MA?

When Mary Herlihy, MD, arrived at Beth Israel Deaconess Medical Center (BIDMC) in Boston, MA, in 2014, many departments were already using OpenNotes, but the Department of Obstetrics and Gynecology (OB/GYN) was reluctant to adopt this style of sharing documentation. Providers were concerned about how patient perceptions about their care might be affected if patients were able to read their own clinic notes. They were also uneasy about the potential impact on workflow. Once they started using OpenNotes, however, most providers did not see a difference in patient care and instead found the new approach useful for identifying inaccuracies or highlighting corrections that needed to be made to the visit record.

Those who were using OpenNotes in other departments at BIDMC relayed to their colleagues in OB/GYN that they didn’t need to significantly alter their writing style when they adopted OpenNotes. In the beginning, they were more cognizant about what they were writing and the quality of their descriptions. They found themselves using terminology that was more sensitive and objective, such as “early pregnancy loss” instead of “missed baby” or “high body mass index (BMI)” instead of “obese.” Unflattering details and extraneous commentary were also omitted so that patients knew there was “no drama in their medical record.” Providers found that their explanation of the care plan improved with minimal effort. For example, if they prescribe a medication for a two-week course, they automatically include details of the dosing regimen in the note so that patients can refer to it at home.

In most situations, OpenNotes did not impact workflows and the process of documentation remained the same. For providers who document their own visits, notes become available to patients as soon as they are finalized. Providers who work with third-party scribes have not noticed a delay in notes being available to patients. In fact, patients often have access to the notes more quickly because the scribe is documenting the visit in real-time. Providers in the department who use voice recognition dictation to document visits are often able to sign off on the dictated notes within 2 to 3 hours of the visit so patients can access their notes on the same day.

“We needed to reinforce that OpenNotes is not much different than a patient having access to their medical records. It was helpful for providers to know that our goal was to more effectively document and outline medical care, not change their documentation style and create more work. We also reassured them that they could withhold certain notes if they chose,” says Dr. Herlihy.

Using OpenNotes in the OB/GYN setting presented some specific risks, for example, the potential for someone other than the patient to find out about sensitive subjects such as prior terminations, domestic abuse, sexual abuse or substance abuse. To mitigate this risk, providers have the option to discuss what should be included in the note with the patient first, then designate on a note-by-note basis what information will be available on the patient portal. The department decided to exclude the family planning group from using OpenNotes because of significant concerns over privacy breaches and the impact of that information being shared. Each patient may have a different opinion about the sensitivity of specific topics and this can be difficult for a provider to predict. Therefore, being professional at all times is key. If a sensitive subject is identified in a note, the provider should use terms that clearly explain the what it is, any lab results and what they mean and, if needed, reassure the patient.

BIDMC OB/GYN adopted OpenNotes in 2015 and patients have been largely silent about the transition. In 2016, OpenNotes began a project asking for detailed patient feedback about their notes, beyond a simple patient satisfaction survey. The goal was to understand in more depth the impact that access to visit notes had on patient perceptions of care, the provider and the notes themselves. It also asked patients to elaborate on the causes of their satisfaction or dissatisfaction. Responses are just starting to come in and they are generally positive. Providers are receptive to the feedback and find the positive comments gratifying. The few negative comments were addressed constructively in real-time to quickly repair and strengthen the provider-patient relationship.

“For many providers, the work they put into caring for the patient wasn’t obvious; now with OpenNotes patients can see it. This evidence strengthens patients’ connections to our providers as their partner in care. Discussion about the visit notes gives a view into what matters to patients beyond what we record about them and this is incredibly valuable for establishing trust. At the end of the day, OpenNotes is good for providers and patients.”

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Downloadable tools

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The tools and resources here can offer implementation support for your practice. You can download and modify them to fit your specific needs.

Complete Adopting OpenNotes toolkit

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Module Completion

Individual tools

  • Adopting OpenNotes: Partnering with Patients

    Download a printable PDF version of this module.

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    PDF, 354 KB

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  • OpenNotes PowerPoint

    Use this PowerPoint presentation to review this module with your team.

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  • Tips for improving notes

    At-a-glance guide on how to write notes in a way that is easy for patients to comprehend.

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  • Email template for introducing OpenNotes to patients

    Use this template email message to introduce OpenNotes to patients.

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  • Email template for introducing OpenNotes to the practice

    Use this template email message to introduce OpenNotes to your practice.

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    MS WORD, 47 KB

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  • Patient FAQs

    FAQ answers to common questions patients may have.

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  • Staff FAQs

    FAQ about OpenNotes for practice staff.

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    MS WORD, 48 KB

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