OpenNotes: Transparent Clinicians' Notes for Health & Illness

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Information about OpenNotes: Transparent Clinicians' Notes for Health & Illness
Health & Medicine

Published on February 20, 2014

Author: MyOpenNotes



Sharing clinicians’ notes with patients is a simple idea for health. This presentation can be used to introduce your institution to the benefits of open notes and how to adopt this practice with your patients. It guides you through the OpenNotes study, which sparked a movement towards more transparent notes across the nation.

Background Background information for using these slides: • OpenNotes began as a research and demonstration project that ran from 2010 to 2011 in primary care in three sites, led by Beth Israel Deaconess Medical Center in Boston. • The study was funded by the Robert Wood Johnson Foundation (RWJF) and published in the Annals of Internal Medicine in October 2012: “Inviting Patients to Read Their Doctors' Notes: A Quasi-experimental Study and a Look Ahead.” The following slides report on these results. • Today, the study investigators and others are expanding OpenNotes beyond primary care and studying further implications for patients, caregivers, and clinicians in specialty care, psychiatry, and more. RWJF continues to fund OpenNotes projects, including an advocacy campaign to make sharing visit notes a routine part of care. • The team has published several papers and maintains the OpenNotes website ( where you can find published papers, news, and other materials.

About the OpenNotes Study Demonstration project summer 2010 – summer 2011 (and still ongoing) Patients invited to view their PCPs’ signed notes via secure portals (only notes signed during the project – not retroactive) Each patient notified automatically via secure e-mail message when a note was signed, and reminded to review note(s) before next visit Patients and doctors completed surveys before and after, and we collected administrative data (portal clicks, e-mail volume) Primarily funded by the Robert Wood Johnson Foundation

The Study’s Three Principal Questions Would OpenNotes help patients become more engaged in their care? Would OpenNotes affect doctors’workflow negatively? After one year, would patients and doctors choose to continue?

Participants 108 volunteer PCPs and more than 19,000 of their patients who use portals • BIDMC (urban and suburban Boston) • 39 PCPs • Geisinger Health System (rural Pennsylvania) • 24 PCPs • 10,300 patients 8,700 patients Harborview Medical Center (inner city Seattle) • 45 PCPs 270 patients (new portal)

PCPs’ Concerns and Experiences (surveys after 12 months experience with open notes)

PCPs’ Main Concerns changes in workflow Pre-intervention (%) BIDMC/GHS/HMC Post-intervention (%) BIDMC/GHS/HMC Visits significantly longer 23/32/21 3/5/0 More time addressing patient questions outside of visits 49/45/34 8/0/0 More time writing/editing/ dictating notes 46/36/34 21/14/0 And, compared to the year preceding the intervention, the volume of e-mails from patients did not change (Delbanco et al, Ann Int Med, 2012)

PCPs’ Main Concerns changes in documentation Changed the way they addressed: Pre-intervention (%) BIDMC/GHS/HMC Post-intervention (%) BIDMC/GHS/HMC Cancer/possibility of cancer 33/18/26 26/18/3 Mental health issues 44/27/53 36/27/11 Substance abuse 38/32/42 28/23/8 Obesity 18/18/21 33/5/5

Patients’ Experiences

Among Patients with Notes (Visits): • 82% opened at least one of their notes • Few patients said reading notes made them • Worried (5-8%) • Confused (2-8%) • Offended (1-2%) • 20-42% shared notes with others

Among Patients with Notes: • 70-72% of patients across the three sites reported taking better care of themselves • 77-85% reported better understanding of their health and medical conditions • 76-83% reported remembering the plan for their care better

Among Patients with Notes: • 69-80% felt better prepared for visits • 77-87% felt more in control of their care • 60-78% among those taking medications reported “doing better with taking my medications as prescribed”

Comments and the Bottom Line

Comments from Patients Weeks after my visit, I thought, "Wasn't I supposed to look into something?" I went online immediately. Good thing! It was a precancerous skin lesion my doctor wanted removed (I did). In his notes, the doctor called me "mildly obese." This prompted immediate enrollment in Weight Watchers and daily exercise. I’m determined to reverse that comment by my next check-up. If this had been available years ago I would have had my breast cancer diagnosed earlier. A previous doctor wrote in my chart and marked the exact area but never informed me. This potentially could save lives. It really is much easier to show my family who are also my caregivers the information in the notes than to try and explain myself. I find the notes more accurate than my recollections, and they allow my family to understand what is actually going on with my health, not just what my memory decides to store.

Comments from Doctors I had to have better documentation, which is a good thing. My fears: Longer notes, more questions, and messages from patients. In reality, it was not a big deal. For me the most difficult thing was having to be careful about tone and phrasing of the notes knowing the patient would be reading them. I felt like my care was safer, as I knew that patients would be able to update me if I didn't get it right. I also felt great about partnering with my patients, and the increased openness.

The Bottom Line for PCPs After a year, PCPs were asked: Taking all considerations into account, I would like my patients to continue to be able to see my visit notes online. Some said no: 26% of BIDMC PCPs 17% of GHS PCPs 19% of HMC PCPs But, when offered the option of turning off open notes at the end of the year-long intervention, not one doctor asked to do so.

The Bottom Line for Patients After one year, 99% of patients wanted to continue to be able to see their visit notes online. When given a choice of doctors or health plans in the future: 4 out of 5 patients said the availability of open notes would impact their choice of provider

The Bottom Line for the Three Institutions All 3 sites decided to expand OpenNotes • Geisinger and Harborview: MDs/ NPs/PAs in ambulatory practices • BIDMC: All clinicians’notes (ambulatory opened in 2013 and inpatient notes planned for 2014)

The Inexorable Rise of Online Access and Transparency Health care becoming more transparent: Open disclosure, lab results, pricing, patient portals, Blue Button… Consumers: • “I don’t know if I want to read my entire medical record, but I want to have it.” (focus group participant) • Government’s direct-to-consumer promotion of HIT • Give Me My DaM Data (Data about Me)

Transparency Makes Headlines The Road Toward Fully Transparent Medical Records Letting Patients Read Doctors’ Notes Consumers Gaining Ground in Healthcare Ten Ways Patients Get Treated Better Inviting Patients to Read Their Doctors' Notes: A Quasi-Experimental Study and a Look Ahead Will Reading Your Doctor’s Notes Lead to Better Health? Should Patients See Their Doctors’ Notes?

OpenNotes: Standard of Care Guest and Quincy. Consumers Gaining Ground in Health Care, JAMA, 2013 Walker, Darer, Elmore, and Delbanco. The Road toward Fully Transparent Medical Records, N Engl J Med, 2013

Patients Pointing toward the Future In the study: 49-56% of patients wanted patient proxies to have access 86-88% of patients wanted access to inpatient notes 59-62% of patients wanted to add comments to their notes 30-40% of patients wanted to be able to approve what is written in a note

OpenNotes is like a New Medicine • Its goal is to help people manage health and illness more effectively • It can have side effects and may hurt some patients • Clinicians and patients will need to learn how to use it well

Future Directions Most organizations adopting OpenNotes begin by sharing clinicians’ notes in ambulatory care. Organizations have or will soon begin sharing notes with: • Caregivers • Psychiatry patients • Inpatients And research continues: • Open notes and patient safety • Open notes and medication adherence • Open notes and end of life care • Patients and clinicians co-generating notes

Join the OpenNotes Movement! Visit the OpenNotes website and sign up for the mailing list Resources for organizations implementing open notes • Toolkit for implementers • Roadmap and advice about key decisions • Sample FAQs for patients and clinicians • Sample communications materials • Resources for evaluators • All open notes surveys are available free of charge • Links to all open notes papers are on the website Need something else? Contact the OpenNotes team: •


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