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Outlines six steps for increasing transparency by adopting OpenNotes
Presents evidence to support the case for using OpenNotes in your practice
Shares resources to help you learn how to write transparently and help clinicians, patients and caregivers make the most of shared notes
Provides case studies and examples from early adopters of OpenNotes
Allowing patients to access information in their medical records can improve the relationship between physicians and their patients. While most practices agree with this viewpoint, they often struggle with how to go about increasing transparency. OpenNotes is an approach that many practices have used successfully to do just that.
Quiz Ref IDOpenNotes is a national initiative working to give patients easy access to their health care visit notes. OpenNotes is not a software package or product, but rather a simple change in how your practice uses its patient portal that's been shown to promote patient engagement and enhance the patient-physician relationship.
The initiative began in 2010 when over 100 primary care physicians across three large medical institutions began sharing notes with their patients. Today, over 70 health systems have adopted OpenNotes and more than 12 million patients can access their notes online. This free process works through existing electronic health record (EHR) and patient portal platforms.
Patients, administrators and everyone on the care team has a role in making patient access to their clinician notes a routine part of health care. This module will outline how the concept of sharing visit notes with your patients can be achieved through OpenNotes. Step-by-step strategies are outlined to guide you in adopting OpenNotes, as well as tips for physicians and the entire care team to maximize the benefits of OpenNotes.
What are OpenNotes? How does OpenNotes differ from a typical clinician note?
There's no difference! The notes that OpenNotes refers to are simply everyday clinician notes made easily available to patients. For many practices, this means notes become accessible through their organization's EHR/patient portal. There's no separate template for this—it simply involves “flipping the switch” and letting patients view notes signed by clinicians, in much the same way lab reports, X-rays and other test results are increasingly being made available to patients online. For those without an EHR or patient portal, printed copies of notes can be shared. Currently, research on OpenNotes and implementation reports have only focused on ambulatory notes, though there are plans to expand OpenNotes into inpatient notes as well.
Is the confidential relationship between patients and clinicians different when using OpenNotes?
No. The relationship remains confidential. Since notes are shared primarily through patient portals, OpenNotes utilizes the security measures already in place on an organization's portal system. The patient will have access to their notes, however, and may choose to share them with whomever they want.
A study published in the Annals of Internal Medicine looking at the effect on physicians and patients of facilitating patient access to visit notes through OpenNotes2 found that:
More than 90 percent of physicians reported that they did not need more time to address patients' questions outside of visits.
Approximately 80 percent of physicians reported taking the same amount or less time to write notes.
Approximately 90 percent of patients opened their notes made available through OpenNotes.
Two-thirds of patients reported doing better with taking medications as prescribed because of OpenNotes.
More than 75 percent of patients reported that OpenNotes helped them feel more in control of their care.
Nearly 90 percent of patients agreed that the availability of OpenNotes would be an important factor in choosing a future doctor or health plan.
Ninety-nine percent of patients and more than three-quarters of physicians wanted OpenNotes to continue.
How can sharing visit notes affect patient safety?
Initial results from an ongoing patient safety research project, known as the OpenNotes Patient Safety Initiative, suggest that sharing visit notes could improve patient safety by:
Helping patients remember recommended tests and procedures, thus preventing diagnostic delays.
Encouraging patients to speak up when they have questions about symptoms, tests or treatment plans. This is especially beneficial for patients whose symptoms do not improve with treatment or patients whose symptoms persist despite negative or inconclusive test results.
Involving informal caregivers, giving them access to information that can help reconcile multiple treatment plans and recommended laboratory tests for chronically ill patients.
Enhancing trust between the physician and patient, leading to less “doctor-hopping” or fragmented care that can result in delayed diagnosis.13
Detecting and correcting errors earlier than current approaches.1
Read more benefits on the OpenNotes website.
Educate your practice about clinical note transparency and OpenNotes
Plan what OpenNotes will look like in your practice
Prepare your practice and patients
Adapt your documentation style as needed
Learn to handle challenging topics in an OpenNotes environment
Collect patient and clinician feedback about OpenNotes to refine your approach
Describe and share research on the many potential benefits to both patients and physicians of giving patients access to their visit notes. In particular, share research that has shown that patients who have access to their visit notes report that they:
Feel more in control of their health care
Have a better understanding of their medical conditions
Are more likely to adhere to their medications
Quiz Ref IDThe research also showed that physicians and other clinicians who shared their notes saw:
Improvements in patient satisfaction, safety, communication and education
Improvements in the patient-physician relationship, including enhanced trust, transparency, communication and shared decision making
Patients better prepared for their clinic visits and becoming more actively involved in their care
Communicate the benefits of OpenNotes to relevant stakeholders in your organization such as practice leadership, your colleagues, staff and patient advocacy groups and/or patient family and advisory councils.
Does using OpenNotes impact office workflows?
There is no evidence of an impact on workflows and physicians are not reporting increased workloads. In fact, many physicians involved in the OpenNotes pilot study were surprised by how little effect the intervention had on their practice workflows. One study found that less than five percent of physicians reported longer visits, with less than 8 percent saying they spent more time addressing patients' questions outside of visits.16 The volume of phone messages and email communication from patients also did not change after OpenNotes was adopted. Some physicians did acknowledge that they took more time to write notes, and many reported writing better and more educational notes.
The most positive impact reported related to the efficiency of the visit. There have been many reports of patients coming to visits better prepared and remembering the care plan between visits with OpenNotes.
Will patients be worried or confused by reading their notes?
During initial rollouts of OpenNotes, many clinicians were concerned that patients wouldn't understand or would misinterpret the information in their notes. However, these concerns have not been evidenced, and other feedback indicates that most patients appreciate the window into what their clinician is thinking. In one analysis, 97 percent of patients understood their notes with little difficulty.1 It's important for clinicians to let patients know that any points of confusion regarding the visit notes can be clarified at the next visit or the patient can ask for help right away if confusion about the notes might impact their treatment.
Quiz Ref IDWhen implementing OpenNotes, it is important to take into account policy considerations that your practice or organization may have. Issues such as which clinicians or departments will share notes, how to introduce patients to OpenNotes, how proxies will access patient notes and how patient requests to change notes will be handled all need to be addressed prior to rollout. Other considerations include whether individual notes can be hidden by clinicians and whether any notes will be shared retroactively. Outline team member responsibilities regarding OpenNotes, such as who will educate patients on registering for the patient portal and how to find their notes within the portal. For those who have an EHR, it is important to work with your vendor to identify any IT needs for implementation, roll out and optimization of the interface for patients and caregivers.
Can OpenNotes be used with any EHR?
While all EHRs capture notes, some have not yet implemented the technical capacity to easily share notes online with patients. As of November 2016, several EHR vendors do have the capacity to provide note access through an organization's patient portal. Be sure to check with your EHR vendor to see if they have this capacity. Other vendors are anticipated to have this capacity in the future and in the meantime, all physicians can still print out their notes for patients.
Can I participate in OpenNotes without a patient portal?
There are many clinicians who have widely shared visit notes with their patients throughout their careers, decades before EHR or online portal technology was available. Though most practices who use OpenNotes share notes electronically through their patient portal, there are several options that may better suit your practice's workflow. Remember that you don't need specialized technology to take advantage of OpenNotes. You may consider sharing the visit notes with patients as a printout that is stapled to the after-visit summary or handed to them as they leave the exam room. This is a convenient option if your practice layout includes a printer located in or near the exam rooms. Printing notes is also helpful for patients who may not be able to access them via computer.
Can OpenNotes be used by any specialty?
Yes. Some specialties, particularly those in which significant patient follow-up is required, could benefit greatly from OpenNotes. Patients can use the notes to understand and share follow-up care recommendations, including physical therapy guidance, referrals and upcoming labs. OpenNotes may also be especially beneficial for patients with complex chronic conditions who are managed across specialties, for patients with impaired cognitive function who see a specialist and those with care partners.
What types of notes should be shared?
Most practices share ambulatory visit notes. While only a few sites are sharing inpatient notes, many provide online access to discharge summaries as a step in that direction. If you are awaiting lab results that will inform your treatment plan, you may consider delaying the release of some visit notes. For example, you may choose to embargo some notes or other health information until you are able to have a phone conversation or follow-up visit with the patient. Practices often delay the release of notes that contain abnormal results so they can be discussed before they are made available to the patient.
What are the roles of individual care team members in making OpenNotes work?
All team members should be aware that the practice is participating in OpenNotes. This means they should have enough understanding to explain the concept and set expectations with patients about where and when they will see their notes. Medical assistants, health coaches and/or front desk staff can assist patients with registering for the patient portal or locating their note once they are registered and logged in.
What kind of protective policies should I put in place as we begin to use OpenNotes?
Depending on the EHR and specific policies within a certain practice, some organizations offer clinicians the option to ‘hide' certain visit notes. Even though research suggests that less than one percent of OpenNotes participants use this option, it still may provide some peace of mind. Some practices also choose to initially exclude certain patients from OpenNotes. For example, the obstetrics/gynecology department at BIDMC decided that the family planning group and its patients would not participate in OpenNotes because of the sensitive nature of these visits and concern about consequences if this information was inadvertently shared. Clinicians may also hide a particular note from a patient in situations where issues need to be discussed in person first.
As with anything new, you may encounter some initial resistance internally when adopting OpenNotes. Prepare your practice and potentially decrease pushback by raising awareness. Discuss the importance of transparency and answer questions about OpenNotes in team meetings, educate team members and patients on the benefits of OpenNotes, and encourage practice-wide participation in implementing the new approach. There are also many opportunities to network and learn about best practices from other organizations and physicians who have already implemented OpenNotes. For example, clinicians at the Mayo Clinic have been sharing all visit notes with patients since 2013.
The more you can prepare everyone involved about the adoption of OpenNotes, the easier the transition will be. Help prepare your patients, team members and all stakeholders by raising awareness. The following are some suggestions for doing so.
To prepare clinicians and practice staff:
Describe and share research on the many potential benefits during team meetings.
Distribute clinician-specific FAQs.
Provide department leaders and/or your organization's CEO with a template email they can send to staff.
Post information about adopting OpenNotes on your practice or organization staff intranet site.
To prepare patients and caregivers:
Send an email introducing OpenNotes and how it will impact them.
Make patient-specific FAQs available in all waiting rooms, in exam rooms, on your patient portal and wherever else your patients may easily access them.
Post information about adopting OpenNotes on your practice or organization website and patient portal.
Promote the adoption of OpenNotes through your practices' and/or organizations' marketing channels such as a practice newsletter, or on Facebook and Twitter.
As your practice gains more experience with OpenNotes, help spread the word and continue to engage your stakeholders by:
Collecting stories from patients and clinicians in your practice who are using OpenNotes and share them through your practices' and/or organizations' marketing channels such as a practice newsletter, or your website.
Asking patients and clinicians to blog about their experiences with OpenNotes.
Committing to track OpenNotes utilization by both patients and clinicians so you can regularly update stakeholders with the findings.
Adding questions about OpenNotes to your patient satisfaction survey.
What are some common concerns clinicians have about OpenNotes and how can we be proactive about addressing them?
The two most common concerns among clinicians are that increasing patient access to their visit notes will require more time and that patients will be upset as a result of reading their notes. It can be helpful to distribute information about OpenNotes to your team, including how few patients report becoming upset and how little impact OpenNotes has had on clinicians' time, as well as tips to minimize challenges. Behavioral health clinicians and those caring for adolescents may be especially worried about increased patient access to notes because of privacy concerns, but many organizations have implemented OpenNotes successfully despite these initial worries.
How should I prepare patients for OpenNotes?
Explain what OpenNotes is and why you are moving to this more transparent method of sharing information about their visit. Describe what visit notes are and what they can expect to see in them. Inform patients that, although the portal will make notes available, it is their choice to decide if they want to read their notes. Depending on the type of EHR your practice uses, you may be able to create an automatic reminder system so patients know to review their notes before their next visit. Reminders are proven to increase note reading rates
Can caregivers, family members or proxies access a patient's visit notes?
It's not uncommon for patients with chronic or complex illnesses to want to share their medical information. Patient safety and confidentiality is paramount and there are protective measures you can take to minimize privacy concerns. First, have a process in place for patients to privately and securely grant access to their records and visit notes to another person of their choosing. Procedures for signing up for proxy access vary across organizations. If your practice has a patient portal, you may have already dealt with this question. Second, if your patient portal allows, let patients know they may have the opportunity to decide which notes can be viewed. Lastly, let patients know that they can retract viewing privileges from a proxy or caregiver at any time.
Are patients charged for accessing their notes like they are for a medical record?
No. Opening notes should be available to patients at no cost. No organization currently using OpenNotes charges for them.
Just because patients will now be able to view the note, that doesn't mean that you or your team need to make dramatic changes to your writing style. In fact, most physicians won't need to make any changes to their speaking or writing style. Convey the need for mindfulness when communicating with patients (either verbal or in written communications) to medical assistants, nurses and anyone else on the team who contributes to team documentation. General communication strategies include:
Speaking or writing only about things discussed with the patient during that visit
Not including commentary that could be interpreted as labeling or judgmental
Being positive and supportive
Avoiding use of medical jargon, acronyms and abbreviations. Not only does this create confusion, but some terms may unintentionally offend patients if they don't know what it means. For example, SOB is commonly used as an abbreviation for shortness of breath that could be misinterpreted as a derogatory remark
Long before the OpenNotes initiative, clinicians worried about how to document challenging topics such as mental health, obesity, substance use, physical abuse, driving privileges, visits with potentially litigious patients or suspicions of life-threatening illness. Sensitive issues clearly require special attention.
Although it is natural to want to curb or avoid some challenging conversations, patients may benefit from direct dialogue. For example, when a clinician notices signs of dementia, depression or impaired driving, chances are that the patient or family members are already worrying about these issues as well. They may find that a balanced discussion helps alleviate their anxiety.
What are some things I should consider when drafting a note about a challenging topic? I'm worried some patients may become scared or angry after they read a visit note and not sure how to prevent that.
The best approach in many situations is to discuss everything you are putting in the visit notes with the patient. Use the same words in conversation that will appear in the notes. Many clinicians already follow this practice and some dictate notes with their patients present. Also, be direct and respectful when addressing concerns with the patient. Document your discussion using supportive language.7 You could also ‘monitor' notes if this functionality is allowed through your EHR vendor.
Certain conditions will require more patient education and reassurance. For example, a patient may become upset when they see something in their notes, such as “chronic kidney disease stage 3.” Be prepared for these concerns, especially if they are common, by providing patient education along with the notes and ensuring that your team is able to respond to the patient's questions.
If you believe that accessing a specific note will upset or harm a patient, you could decide to make that note “private” if your EHR has this option. The note will remain part of the patient's medical record and will be available to them if they ever request their complete file. Remember that HIPAA entitles patients to obtain copies of their complete medical records. Independent of OpenNotes, it is best to write notes with the understanding that patients may read them. If you're uncertain about security or a patient becoming combative about what is documented, contact a supervisor or risk management officer at your organization before sharing the notes.
Does it take longer to draft a transparent note on a sensitive issue?
In the initial OpenNotes study, only a few clinicians reported changing the way that their notes addressed these topics. This ultimately did not result in more time preparing their notes, but they found themselves using different language as they were drafting the notes.
What are the benefits of using transparent notes to address sensitive health issues?
Clinicians in the OpenNotes study found that when some patients read visit notes about obesity or substance abuse, they were more motivated 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.
To fully understand the impact OpenNotes is having on your practice, measure the process from start to finish—establish a baseline, a midpoint and an endpoint for your OpenNotes initiative. You can collect information on the use of and perspectives about OpenNotes through informal hallway conversations, at team meetings and by adding questions about OpenNotes to your patient satisfaction survey. Another option is to track the volume of patient emails and phone calls before and after OpenNotes as an indirect measure of the effect of OpenNotes on time spent by clinicians fielding patient questions. Work with your EHR vendor or IT team to quantify how many patients view their notes via the patient portal.
Have organizations witnessed an uptick in requests for changes to the medical record after implementation of OpenNotes, and how is this tracked?
Anecdotal evidence suggests that organizations currently using OpenNotes are not seeing an increase in the number of requests for changes to the medical record. Requests for changes typically come from the same patients who were asking for them before the use of OpenNotes.
How long does it take for OpenNotes to become routine?
It varies but it usually doesn't take long. Most practices are surprised by how much of a non-event transitioning to OpenNotes is. The longest implementation process tends to be experienced by organizations who adopt an ‘opt-in' approach where only select clinicians or departments are participating.
What does the future of OpenNotes look like?
Practices are encouraged to innovate and tailor how they use OpenNotes to increase patient involvement in collaborative care. As you explore new features and functionality for your patient portal, consider ways that you can make it easier for patients to contribute to their medical records and visit notes. Some ideas for engaging patients include:
Equipping patients to upload home measurements, such as blood pressure and glucose readings
Enabling patients to update or correct family and social histories in their own words
Sending automatic email reminders when a new note is signed and ready to read
Other physicians who are experienced with OpenNotes are excited by finding new ways in which their patients can obtain their health information easily. They encourage patients to register for the patient portal, describing it as an extension of their practice. These physicians also encourage their patients to ask questions through email and text.
“Partner with your patients to improve care #STEPSforward”
OpenNotes is a method to engage patients and increase transparency by sharing clinician notes with patients. Quiz Ref IDSharing notes can empower patients to be more active participants in their care, making them more likely to follow through on treatment recommendations. OpenNotes usually does not require additional clinician time or effort during a visit to have a positive impact on a practice and its patients.
Although studies are underway nationally, there is still much to learn about eliciting and responding to patient preferences and understanding 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 and team meetings will bolster the collective wisdom and skill in writing transparent notes over time. You may find it helpful to regroup as a team after completing this module to share your experience.
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AMA STEPS Forward™ presents actionable, practical toolkits and customizable resources that you can use to successfully implement meaningful and transformative change in your practice or organization. See How it Works
About the Professional Satisfaction, Practice Sustainability Group: The AMA Professional Satisfaction and Practice Sustainability group has been tasked with developing and promoting innovative strategies that create sustainable practices. Leveraging findings from the 2013 AMA/RAND Health study, “Factors affecting physician professional satisfaction and their implications for patient care, health systems and health policy,” and other research sources, the group developed a series of practice transformation strategies. Each has the potential to reduce or eliminate inefficiency in broader office-based physician practices and improve health outcomes, increase operational productivity and reduce health care costs.
The project described was supported by Funding Opportunity Number CMS-1L1-15-002 from the U.S. Department of Health & Human Services, Centers for Medicare & Medicaid Services. The contents provided are solely the responsibility of the authors and do not necessarily represent the official views of HHS or any of its agencies.
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