These FAQs address questions often posed by clinicians.
Health Care Professionals FAQs
What is OpenNotes?
OpenNotes is not a product or software, but rather a movement to offer patients ready access to the health care notes doctors, nurses, and other clinicians write after a clinical appointment or discussion. Opening notes helps patients to read material that, through the federal Health Insurance Portability and Accountability Act (HIPAA), is already theirs to review and copy.
In 2010, 105 volunteering doctors and 20,000 of their patients completed a one-year, multicenter trial of OpenNotes. In this research and demonstration project, primary care doctors invited patients to read their signed visit notes. At the end of the year, patients overwhelmingly supported the program and cited multiple health benefits. Doctors saw benefits for patients and little burden for themselves. At the end of the study, both patients and doctors wanted to continue to share notes.
Why share notes?
Engage Your Patients. The yearlong, multi-center OpenNotes study found approximately 4 out of 5 patients, when actively offered the opportunity, read their notes. More recent research suggests that sending email reminders when notes are available to be read is a very effective way to continually engage patients.Patients who read notes report that they:
- have a better understanding of their health and medical conditions;
- recall their care plan more accurately;
- are better prepared for visits;
- feel more in control of their care;
- take better care of themselves;
- more frequently take their medications as prescribed; and
- have better conversations and stronger relationships with their doctors.
Promote Patient Safety. Patients may notice errors in their notes. Correcting them and making the record more accurate may improve patient safety.
Help Caregivers Optimize Care. Many patients, including chronically ill or elderly patients, rely on family members or other care partners to coordinate appointments, tests, medications, and general care plans. Data shows that care partners benefit from note sharing as much as the patients themselves.
Patients Want It. The vast majority of patients want ready access to their notes (and they have the legal right to such access). In the OpenNotes study, approximately 4 out of 5 patients read their notes.
Even if patients may not understand everything in the notes, they indicate strongly that this type of transparency and partnership is valuable to them.
In the initial study, a great majority of patients said the availability of OpenNotes would influence their future choices of doctors and health plans.
How should I approach writing about sensitive issues?
A minority of doctors in the initial OpenNotes study reported that they changed how they documented sensitive topics, including mental health, obesity, substance abuse, sexual history, elder, child or spousal abuse, driving privileges, or suspicions of life-threatening illness. This is not a new dilemma, but it gains urgency in an era of shared visit notes.
Some Things to Consider:
- Unless you believe a conversation might harm your patient, a good rule of thumb is to write about things you discussed, and conversely, to talk about content you will write about with your patients. Many clinicians already follow this practice. For instance, some dictate notes with their patients present. If you have concerns about how to document encounters that may relate to potential litigation, please contact a risk manager.
- Although it is natural to want to curb or avoid some challenging conversations with patients, patients may benefit from direct dialogue. For example, when a clinician notices signs of dementia, malignancy, or impaired driving, chances are good the patient or family members already worry about these possibilities. They may find a balanced discussion helps with the anxiety they may otherwise hold alone.
- In addition, providers in the initial OpenNotes study found that when patients read their notes about obesity or substance abuse it motivated some to attempt difficult behavioral changes. Some patients reported that “seeing it in black and white” made it more real. As an overarching strategy, promoting transparency may encourage more open and active communication in these challenging areas.
- But some patients may not benefit. You can compare OpenNotes to a “medicine” – helpful for most, but harmful to some, with “side effects” and “contraindications” to consider. If you believe that accessing a specific note may harm a patient, you can consider using your usual EHR mechanism or talk to an institutional representative on how to write a “private” note. Remember that HIPAA entitles patients to obtain copies of their complete medical records, including such private notes. Therefore, independent of OpenNotes, it is best to write notes with the ongoing understanding that patients may read them.
- Without a doubt, documentation of “sensitive topics” warrants more research. Some studies are underway nationally, but we have a lot to learn about eliciting and responding to patient preferences and how documentation affects desired health outcomes. In the meantime, sharing stories about OpenNotes — good and bad — in appropriate settings, and incorporating such experiences in case discussions, conferences, team meetings, etc., will over time bolster our collective wisdom and skill.
Will I need to change the way I write my notes?
Doctors in the initial OpenNotes study did not report changing the way they wrote their notes. Clinicians who now have more experience with note sharing, report that over time, their note writing has changed, but in general they perceive the changes as making their notes better.
In general, patients do not expect doctors to write notes in layperson language. They are not bothered by terms they don’t understand and report researching terms, preparing better questions for clinicians and in general feeling fortunate to have a window into more information about their own health. Nonetheless, the following suggestions may help maximize the educational potential of notes.
- Avoid jargon or abbreviations, especially ones that patients might easily misinterpret (e.g., “SOB” or “patient denied”).
- Patients may also benefit from the list of common abbreviations on MedLine Plus, where they may also look up medical terms or diagnoses.
- Briefly define medical terms when feasible.
- Incorporate lab or study results into your notes to give patients the full picture.
- Include educational materials or trusted links to content for your patients.
- Be mindful of sensitive topics and remember patients have rights under HIPAA to access their record.
What if patients disagree with what I wrote and want the note changed?
Changing a note is at the clinician’s discretion. If you feel the change improves the note, you can simply document the change as an addendum or use the usual mechanism in place at your institution to edit/correct a note. In the OpenNotes study, patients rarely requested that clinicians change the record. Though not studied, institutions report no uptick in the request for changes to the record after the implementation of OpenNotes.
New research suggests that allowing patients, families and care partners to review the notes may help them identify clinically important inaccuracies, address confusion about the care plan, or find lapses in follow up that, once rectified, improve safety.
Will sharing notes with patients take more time?
Patients generally respect clinicians’ time, and most doctors report little, if any, impact on their daily practice. Indeed, many doctors in the initial study reported forgetting they were participating once it was underway. But some say they take more time to write notes, and many report writing better and more educational notes. Only a small minority report that participating in OpenNotes takes more time, while others indicate that it saves time.
Will patients contact me more between visits?
While some patients may contact you after reading their notes, experience to date is that this is uncommon. Moreover, many clinicians find that giving patients the ability to respond to the notes improves patient care and satisfaction. Contrary to what some clinicians might fear, patients may contact you less by virtue of ready access to their notes.
Will this practice increase my liability?
Data on liability risk with other forms of transparent communication in health care, such as disclosure of medical error, suggest open and honest communication may decrease lawsuits (Kachalia, Ann Intern Med 2010). Some providers list improved patient safety as the “best thing” about OpenNotes. For any specific concerns about how to document something in your notes, contact your supervisor or risk management officer.