Help your health system make the best of open notes for patients and care partners

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Between now and the April 5 federal mandate of the implementation of the 21st Century Cures Act Info Blocking Rule, we’re answering your top questions about the open notes aspect of the rule.
In several studies of how open notes affect the way doctors prepare notes, the majority report they don’t change the way they write their notes. But many clinicians experienced in sharing notes report their writing does change over time, feeling overall that it becomes more valuable, certainly to patients. Few report “dumbing down” their language, but they find themselves using fewer abbreviations and trying to avoid language that could appear judgmental to patients. Some report modulating their practice such that they become “teaching notes.”
In general, patients do not expect doctors to write notes in layperson language, and more than 90% in one large study report understanding their notes well. Patients not bothered by terms they don’t understand, and they are happy to research terms. They feel reading notes helps them prepare more focused questions for clinicians. Overall, they express considerable enthusiasm for having a window into more information about their health.
Resources:
Tip Sheet: Suggestions for implementing open notes in clinical practice, OpenNotes.org
How to write an open note for patients, CT Lin, MD
Under the new federal mandate, in certain specified situations information can be blocked (or “hidden”) from patient access on online portals—these are called Exceptions. As examples, clinicians can block notes
• If they believe a patient will harm another person or themselves as a result of reading a note
• If they need to protect the security of another person’s electronic health information (e.g., a mother’s health information in a child’s record)
Unless one of the Exceptions applies, clinical notes must not be blocked. Details about exceptions are outlined at HealthIT.gov.
Learn more about how the Cures Rule applies to open notes.
We’ve spent more than 10 years studying the effects of open visit notes on patients, care partners and clinicians. Time and again, studies show that open, transparent communication through visit notes are a good thing, across all demographics, and the majority of clinicians with experience with open notes feel it is a good idea and would recommend it to colleagues
This website serves as the “library” of the OpenNotes movement. You are likely to find many answers to your questions if you take a little time, review a newsletter, or sign in to one of our past or future webinars. In addition, several places on this website detail research and best practices about open notes in special circumstances. Check them out.
In advance of open notes, clinical staff more often than not anticipate significant changes to workflow and workload. However, time after time we hear such worries proved misplaced. Among the >260 organizations that implemented open notes prior to November 2020, not one reported a significant increase in visit time with patients or in e-mail traffic. In fact, some reported a decrease in e-mail, as patients are able to resolve confusion or forgetfulness by reading their notes.
Patients generally respect their provider’s time, and most doctors report little, if any, impact from patients on their daily practice. Indeed, once underway, many report forgetting they were participating in a new intervention. But in recent surveys, about one in three doctors report taking somewhat more time to write notes, with fewer than 10% reporting taking much more time. We do not have independent verification of such reports. However, more than a few tell us that initially they took more time, but once settled in with this new transparency, they prepare their notes with the same efficiency as in the past.
Resources:
In numerous studies across multiple specialties, the majority of patients (93-99%) reported that reviewing their notes made them feel the same or better about their doctor, and more than half of the doctors participating reported that sharing notes led to improved patient satisfaction and trust.
Evidence is mounting: Sharing notes with patients can lead to better communication, more collaborative decision-making and stronger relationships. Perhaps most importantly, open notes can be powerful tools for enhancing patient engagement, and considerable research demonstrates that engaged patients have better outcomes.
Learn how open notes adds to the therapeutic appliance, builds stronger relationships and improves patient engagement.
Open notes can assist and support family, friends, and others who are care partners and caregivers. Forty percent of patients who read notes report sharing them with others, primarily family members. Shared notes help care partners manage the health needs of the people in their care, including scheduling visits, reconciling medication lists, and following through on a host of recommendations.
Importantly, transparent communication may be a powerful way to diminish stress and morbidity in the care partners themselves. In a recent study, care partners reported benefits from note sharing similar to those reported by patients. Additionally, care partner access to notes can serve as a bridge for patients with limited English, low health literacy, and those without computers or access to the Internet.
Enhancing mechanisms that offer ready proxy access to portals for care partners is clearly an important national work-in-progress. OpenNotes is engaged in research focusing on best practices and enhancing processes that meet the needs both of the individual patients and those caring for them.
During COVID
Care partners are often under enormous stress, and the Covid-19 pandemic has magnified virtually all the contributing factors. Transparent communication can play a large role in diminishing burdens care partners themselves experience.
View the Care partner toolkit to learn more.
Improved adherence to medications may be the most important clinical benefit transparent communication can confer. In a study published in 2019, a majority of patients reported that open notes improved their understanding of why and how to take their medications, and one out of six patients surveyed reported that open notes led them to adhere to their regimen more closely. Given that poor adherence to medications may cost the health care system as much as $300 billion dollars annually, this finding has striking implications.
In interviews and focus groups with patients and families, we have repeatedly heard anecdotes supporting these survey findings. Moreover, a study by the Geisinger Center for Health Research found that patients in practices offering access to notes were more likely to fill their prescriptions for blood pressure medication than were those in practices whose notes remained hidden.
Resources:
The digital divide persists. Individuals who do not usually speak English at home, have less than high school education, are nonwhite, older, or Hispanic are not as likely to register on patient portals and are therefore less likely to read their notes. However, in repeated studies, when these patients do get to read notes, they are those most likely to report benefits from note reading. Safety net institutions around the country, both hospitals and community-based health centers, have been joining the OpenNotes movement, and we receive many positive reports.
Resources:
Open Notes for Health Professionals
Navigating patient portals remains a challenge for patients. Patients often give up before finding what they need, and this includes finding notes. Health systems that make it easy for patients to access notes find that more patients choose to register for their portals and use open notes to full advantage.
Resources:
OpenNotes white paper: Implementing Open Notes: Improving patient access to notes on portals
OpenNotes Grand Rounds recording: Improving Portals for a Better Patient Experience
Most patients do not know that their notes are available for review. Indeed, more than a few don’t realize that clinicians write notes following visits.
Patients benefit from messaging about notes and your portal through multiple platforms, including posters, handouts, social media, email, text messaging, and person to person communication by members of the health team. A study of two health organizations, one with an electronic reminder system, and one that stopped reminding patients half way during a 2-year period, showed that patients viewed their notes far more often when accompanied by an email notification.
If you have an active Patient and Family Advisory Council (PFAC), we strongly recommend involving them in developing your communication materials about open notes.
Resources:
OpenNotes Communications Toolkit
OpenNotes Patient-Family Advisory Council Toolkit
OpenNotes Grand Rounds recording: Improving Portals for a Better Patient Experience
We’ve spent over 10 years studying the effects of open visit notes on patients, care partners and clinicians in a broad variety of ambulatory care settings. Time and again, studies show that open, transparent communication through visit notes are a good thing, across all demographics, and clinicians think open notes are a good idea.
Now, as a result of the Interoperability and Information Blocking Rule, all progress notes must be shared—including inpatient and emergency department notes. Since the focus of investigators has primarily been on office practice, we know little about the effects of sharing notes on inpatient services and in emergency rooms.
But there is developing experience. Learn with us: Tune-in to this Webinar case study about Open Inpatient Notes at UC San Diego Health on March 23.
Resource:
We study the effects of open visit notes on patients, clinicians, and care partners. We have not addressed test results released to patients through online portals. But there is considerable experience nationally with this issue. Using portals, some systems have invited patients to review such results for more than 20 years. These practices are quite variable. Some release everything the minute results are available. Others have selective embargoes…a CT scan or MRI may be published 48 hours later; pathology reports may be “blocked” for 2 weeks, and so on.
Now, with the Interoperability & Information Blocking Rule, we are hearing some consternation about the timing of the release of test results. Ideally, individual patients could specify their own processes. In our informal discussions with patients, some want immediate availability; others prefer to hear first from their clinicians, particularly if bad news could be on the horizon.
We know of little empirical evidence quantifying such divergent views. Our sense is that “embargoes” are in flux, and some EHR vendors are also enabling clinicians to make case by case decisions to block or delay results, hopefully with the individual patient’s needs and desires firmly in mind. This may become an example of where the “letter of the law” specifies one thing, and evolving “common law” heads in a somewhat different direction.
Ideally, patients should have a choice in the information they want to see, and when they want to see it. Overall, we are learning patients want to be in more control of their health information. This Information Blocking rule is an opportunity to invest in research and technologies that allow people to set their own information preferences. As portals and apps evolve in the future, offering patients more and more options will be part of a rapidly changing landscape of care.
Help your health system make the best of open notes for patients and care partners
Inviting Patients to Read Their Doctors’ Notes: A Quasi-experimental Study and a Look Ahead Annals of Internal Medicine (2012)
As a patient and family advisor, you clearly know what it means to be activated and engaged. Patients, family advisors and activists have long been leaders in speaking up about the need for more transparency in health care and for partnerships with clinicians in managing care. Open notes represent an important step in making fully transparent communication a reality.
OpenNotes is a national movement encouraging doctors, nurses, therapists, and other health care professionals to share the visit notes they write with the patients they care for. When a visit note is shared, it becomes an “open note.”
The notes clinicians prepare and place in medical records are more detailed than “after visit summaries” patients receive after a visit to a clinician. The Health Insurance Portability and Accountability Act (HIPAA) provides patients with the legal right to access complete visit notes, but until recently the only option was to go through a sometimes arduous, lengthy, and costly process to obtain records. OpenNotes started because its founders felt patients and their family members would benefit from easy access to their full medical records, including visit notes.
As of April 5, 2021, all U.S. healthcare systems are required to electronically share clinicians’ visit notes with patients at no charge. This is required as part of the 21st Century Cures Act program rule on Interoperability, Information Blocking & ONC Health IT Certification. In theory, all patients who are registered on their health systems’ patient portals should now have easy access to their visit notes. However, a lot will depend on how health systems implement open notes and how they educate and inform both their staff, and patients and families. Many patients are unaware of the benefits of open notes and don’t know they can have access to their notes. There is much work to be done to bring open notes to the attention of patients and families. This is where the PFAC comes in!
“Open notes allow my doctors and me to be on the same page about what we discussed and how we should proceed, as well as to sort out any inconsistencies. Our family also found open notes invaluable when a member became incapable of managing her own health care, and information needed to be shared among multiple caregivers. I can’t imagine going back to “the old days.”
— Naomi Price, Patient Advocate and Consumer Representative, Northwest OpenNotes Consortium
At Kaiser Permanente Northwest, Naomi Price, a member of the PFAC at the time, learned about OpenNotes and brought it up as a topic for consideration at a PFAC meeting. Around the same time, the system’s informatics team also became interested in displaying open notes.The PFAC strongly supported bringing open notes to Kaiser Permanente Northwest and partnered with the informatics team to present the ideat to the Board of Directors. According to Jonathan Bullock, Program Manager for Patient and Family Centered Care at Kaiser Permanente Northwest, it was the patient presence and advocacy at that meeting that convinced the Board to go ahead with OpenNotes and led them to decide to do a “big bang” implementation, launching across the whole system at once.
The OpenNotes website has a lot of good information, including research publications, toolkits, webinars, and patient stories. Encourage your PFAC members to spend some time looking at the website to learn more.
Some quick facts: In a 2010 OpenNotes study, 99% of patients wanted open notes to continue, and 85% said the availability of open notes would affect their future choice of provider. Why?
“The concept of sharing clinic notes with patients will allow patients/caregivers to participate to a greater extent in their own care. As a patient, I am very excited to be able to review my clinic notes “at my own leisure” since all of the information is not always easy to absorb at the time of the visit. As a patient/family advisor, I participated as part of the committee planning open notes at UVM Medical Center. These meetings involved a lot of discussion between physicians, staff, and patient/family members. This allowed everyone to consider different viewpoints about the best way to roll out open notes, tailoring it to our specific medical center. I highly recommend that other centers considering open notes include patient/family input in the planning process.”
— Margery Rosenblatt, University of Vermont Medical Center Patient/Family Advisor
Develop a plan with PFAC members about the steps you’ll take to communicate with key health system decision-makers.
In 2016, UVM Medical Center formed an open notes work group that included three patient/family advisors and representatives from departments across the system. The group was charged with making recommendations to the system’s leadership leading up to the implementation of open notes. PFAC members continued to participate in the workgroup following implementation in an oversight role. The University of Vermont Medical Center (UVM) started offering open notes in June of 2017.
“Having patient/family advisors as part of the working team was invaluable as we worked to make recommendations for what open notes will look like at the UVM Medical Center. They were incredibly committed to the process, skilled at asking the difficult questions and respectfully challenging the group when there was resistance or reluctance, and also very interested in working towards solutions that would meet the needs of both patients and providers. I feel confident in saying that we would not have been able to move forward as quickly or as unified as we have been without the voice of the patient at the table.”
Amy Cohen, Patient- and Family-Centered Care Program Manager
The PFAC has an important role in informing and educating patients and families about open notes and about the importance of registering on the patient portal. In addition to individual advisors sharing information through personal networks, you can work with your health system’s marketing and communications staff to develop materials (see examples on the open notes website) including:
After implementation, there are opportunities to improve open notes. Advisors should periodically give feedback and guide any recommended changes.
Beth Israel Deaconess Medical Center’s (BIDMC) hospital-wide PFAC has provided feedback on open notes and recommendations for improvements. Members have also advised the OpenNotes research team on projects related to patient experience, safety, and co-production of notes.BIDMC patients have also publicly shared their open notes experiences, in partnership with staff, at conferences and in articles.
We have many useful resources and can connect your system with other similar healthcare systems that have implemented and/or have faced similar challenges and concerns.
Share your PFAC’s open notes story with us! We are always looking for examples of how PFACs partner with health systems to advance the effectiveness of open notes.
For more information, contact: Deb Wachenheim, Assistant Director, Dissemination, at dwachenh [at] bidmc.harvard.edu.
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