OurNotes for Health Professionals: Creating Notes With Patients

The OurNotes process for patients

Prior to a scheduled visit, patients are asked to review their prior opennotes, and then:

1. Prepare and submit a brief (300 words or less) interval history describing how things have gone since a previous visit, and
2. Prepare and submit their two or three 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.

OurNotes Project Team

Principal Investigator

Jan Walker, RN, MBA, Co-Founder, OpenNotes, Associate Professor of Medicine, Harvard Medical School and Beth Israel Deaconess Medical Center

Co-Investigators

Tom Delbanco, MD, Co-Founder, OpenNotes, John F. Keane & Family Professor of Medicine, Harvard Medical School and Beth Israel Deaconess Medical Center

Matt Germak, MD, MPH, Director of Quality and Patient Safety for Primary Care, Beth Israel Lahey Health

Gila Kriegel, MD, Internist, Beth Israel Deaconess Medical Center, Assistant Professor of Medicine, Harvard Medical School

Sara Jackson, MD, MPH, Director, Adult Medicine Clinic, Harborview Medical Center, Associate Professor of Medicine, University of Washington School of Medicine

CT Lin, Chief Medical Information Officer, UC Health, Professor of Medicine, University of Colorado School of Medicine

Stephen Liu, MD, MPH, Internist, Dartmouth Hitchcock Medical Center, Associate Professor of Medicine, Geisel School of Medicine at Dartmouth University

Tom Payne, MD, Internist, UW Medicine, Professor of Medicine, University of Washington School of Medicine

Collaborators

Sigall Bell, MD, Director of Patient Safety, OpenNotes, Associate Professor of Medicine, Harvard Medical School and Beth Israel Deaconess Medical Center

Cait DesRoches, DrPH, Executive Director, OpenNotes, Associate Professor of Medicine, Harvard Medical School and Beth Israel Deaconess Medical Center

Leonor Fernandez, MD, Internist, Beth Israel Deaconess Medical Center, Assistant Professor of Medicine, Harvard Medical School

Steve O’Neill, BCD, JD, Clinical Instructor of Social Medicine, Faculty Associate, Center of Bioethics, Harvard Medical School

OurNotes Research Partner Organizations

• Beth Israel Deaconess Medical Center, Boston, MA
• Dartmouth-Hitchkock, Hanover, NH
• UC Health, Denver, CO
• University of Washington, Seattle, WA

Funder Recognition

The Commonwealth Fund

Drane Family Foundation