What is OpenNotes?
OpenNotes is a national initiative working to give patients access to the notes doctors, nurses, and other clinicians write after a clinical appointment or discussion.
Inviting patients to read their clinicians’ notes can help to improve communication between patients and providers. It can help to increase patients’ understanding of their medical issues. And it can encourage them to take a more active role in making health care decisions and managing their health.
Many health care institutions across the country have adopted open notes—the practice of sharing notes with patients. By partnering with healthcare providers and other organizations, the OpenNotes team hopes to encourage the nation to make shared visit notes the norm, rather than the exception.
Why Share Notes?
As a patient, you have the right by federal law to read the notes your doctor or clinician writes about you. Reading and discussing your notes with your doctor or family member can help you take better control of your health and health care.
Our research shows that, by reading notes, patients:
- Remember more of what is discussed during visits
- Feel more in control of their care
- Are more likely to take medications as prescribed
- Can share notes with their caregivers, helping them stay up to date on progress and treatment
As a clinician, you may build trust and better relationships with your patients by sharing your visit notes. Opening up visit notes to patients has the potential to make care more efficient, improve communication and, perhaps most importantly, engage patients more actively in their health and health care.
By sharing notes, clinicians:
- Promote constructive communication and engagement
- Can help patients become better prepared for visits
- Help patients maintain health and improve their management of chronic conditions
- Can help patients’ caregivers optimize care
As a healthcare administrator, you have an unusual opportunity to enhance customer service and lead with innovation. Opening up visit notes signals your institution’s determination to engage patients as partners in their healthcare.
Opening up visit notes also has the potential to:
- Help patients and clinicians prevent medical errors and improve patient safety
- Reduce healthcare costs through better communication, adherence to medications, and more efficient use of a clinician’s time
Read the Factsheet: OpenNotes: Results
Watch the Video: A “New Medicine” with Clear Benefits
How Does It Work?
Doctors and patients don’t need a specific technology or software to share visit notes. Clinicians can provide patients with access to visit notes electronically, using secure email or patient portals, or they can simply print copies of notes at the end of a visit…or send them later by mail.
Electronically: Electronic health records and patient portals make it easy to share notes with patients. Once signed by the clinician, patients can read an electronic note on a password-protected portal. Moreover, signed notes can trigger emails notifying patients that their notes are ready to view. Talk to your electronic health record vendor about how to offer visit notes to patients.
Print: Doctors can easily email or mail copies of typed or hand-written notes to patients.
Encourage your clinicians to print out or copy their notes for patients. Encourage patients to ask their clinician for copies of their visit notes.
Sharing notes does not change the clinicians’ longstanding pledge of confidentiality. As always, only clinicians involved in a patient’s care will have access to the notes. However, patients may choose to share their notes with caregivers, family members and others. The note is confidential. Whether or not it remains private is up to the patient.
How OpenNotes Began
More than 19,000 patients and 105 primary care doctors participated in a 12-month trial in which patients were invited to read their doctor’s visit notes.
At the end of the study period, 99 percent of patients wanted to continue sharing visit notes, and at the end of a year no doctor asked for the notes to be turned off.
Read the full findings in the Annals of Internal Medicine.
The study was supported by the Robert Wood Johnson Foundation, the Drane Family Fund and the Florence and Richard Koplow Charitable Foundation.
Join A National Movement
The original OpenNotes study sites— Boston’s Beth Israel Deaconess Medical Center, Pennsylvania’s Geisinger Health System and Harborview Medical Center in Seattle—are each pursuing a broader rollout of open notes, and the VA health system has now made notes available to over a million patients. MD Anderson Cancer Center, the Mayo Clinic, and Cleveland Clinic also provide online access to notes. Many other health systems across the country are planning to make notes available to their patients. See the full list of participating sites.
How Do I Get Involved?
Patients, clinicians and health care administrators all have a role in making open notes a routine part of health care.
Check out the toolkit Getting Started With OpenNotes. It offers step-by-step strategies to help you implement open notes in your health system, including tips for both patients and clinicians.
Use these documents to help you make the case for open notes to clinicians and decision-makers in your institution.
Fact Sheet: What is OpenNotes?
Fact Sheet: OpenNotes Results
View and use the presentation on Slideshare.
Teleconference Presentation by Tom Delbanco and Jan Walker
Presented to Scottsdale Institute on February 11th 2014. Listen to the teleconference.
Use these tools to help guide clinicians in sharing their notes with patients.
Writing Fully Transparent Notes
Clinician Frequently Asked Questions
Use these tools to publicize open notes and help patients and caregivers make the most of shared notes at your institution.
Tip Sheet: Launching Your OpenNotes Program
Patient Frequently Asked Questions
Use these surveys to measure the impact of your open notes at your institution.