OpenNotes is exploring a new way to improve communication and shared decision-making. The “OurNotes” initiative asks clinicians and patients to create notes together.
Detailed project description
OurNotes has two principal goals:
- To engage patients (and often their families) more actively in their care, and
- To help make visits more focused and efficient for both patients and clinicians
OurNotes draws on the insights of Lawrence Weed, creator of the “SOAP” notes well-known to clinicians. It asks patients to compose an interval history, the “S” (subjective) component of a note, and to express their goals for a visit.
The hypotheses: OurNotes will a) increase patient engagement, b) bring more focus and structure to encounters, c) promote shared decision-making, and d) off-load some work from clinicians.
The process for patients
Prior to a scheduled visit, patients are asked to review their prior open notes, and then
- prepare and submit a brief (300 words or less) interval history describing how things have gone since a previous visit, and
- prepare and submit their 2 or 3 most important goals or questions for the visit
Patients send these OurNotes pre-visit forms to an electronic health record (EHR) through secure, Internet patient portals on which they have registered. The content of the forms then becomes part of their medical records, with mechanisms varying according to the local EHR system.
The process for clinicians
Clinicians review the patients’ submissions prior to or during visits, and then either refer to them or incorporate them into the visit note itself.
Telemedicine and OurNotes
With the rapid adoption of telemedicine triggered by the Covid-19 pandemic, in addition to preparing their narrative histories and goals, patients are including some of the “pre-work” typically performed by medical assistants prior to face to face visits.
The OurNotes pre-visit forms ask patients to update medications they are taking and to indicate which need to be refilled. In addition, if feasible for the individual or family, patients submit their weight, temperature, blood pressure, and even their blood sugar or oxygen saturation if indicated.
OurNotes so far…
Both the patients and doctors participating in OurNotes pilot programs have offered positive reports. The practice is now spreading rapidly, both for telemedicine and in-person visits.
OpenNotes will develop OurNotes educational programs for patients, families, and clinicians. We will work with EHR vendors to incorporate OurNotes efficiently into both the patient’s and clinician’s workflow. And we plan to develop mechanisms to involve family care partners actively in OurNotes.