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Adopting OpenNotes in Boston, MA: A Case Study

When Mary Herlihy, MD, arrived at Beth Israel Deaconess Medical Center (BIDMC) in Boston, MA, in 2014, many departments were already using OpenNotes, but the Department of Obstetrics and Gynecology (OB/GYN) was reluctant to adopt this style of sharing documentation. Providers were concerned about how patient perceptions about their care might be affected if patients were able to read their own clinic notes. They were also uneasy about the potential impact on workflow. Once they started using OpenNotes, however, most providers did not see a difference in patient care and instead found the new approach useful for identifying inaccuracies or highlighting corrections that needed to be made to the visit record.

Those who were using OpenNotes in other departments at BIDMC relayed to their colleagues in OB/GYN that they didn't need to significantly alter their writing style when they adopted OpenNotes. In the beginning, they were more cognizant about what they were writing and the quality of their descriptions. They found themselves using terminology that was more sensitive and objective, such as “early pregnancy loss” instead of “missed baby” or “high body mass index (BMI)” instead of “obese.” Unflattering details and extraneous commentary were also omitted so that patients knew there was “no drama in their medical record.” Providers found that their explanation of the care plan improved with minimal effort. For example, if they prescribe a medication for a two-week course, they automatically include details of the dosing regimen in the note so that patients can refer to it at home.

In most situations, OpenNotes did not impact workflows and the process of documentation remained the same. For providers who document their own visits, notes become available to patients as soon as they are finalized. Providers who work with third-party scribes have not noticed a delay in notes being available to patients. In fact, patients often have access to the notes more quickly because the scribe is documenting the visit in real-time. Providers in the department who use voice recognition dictation to document visits are often able to sign off on the dictated notes within 2 to 3 hours of the visit so patients can access their notes on the same day.

“We needed to reinforce that OpenNotes is not much different than a patient having access to their medical records. It was helpful for providers to know that our goal was to more effectively document and outline medical care, not change their documentation style and create more work. We also reassured them that they could withhold certain notes if they chose,” says Dr. Herlihy.

Using OpenNotes in the OB/GYN setting presented some specific risks, for example, the potential for someone other than the patient to find out about sensitive subjects such as prior terminations, domestic abuse, sexual abuse or substance abuse. To mitigate this risk, providers have the option to discuss what should be included in the note with the patient first, then designate on a note-by-note basis what information will be available on the patient portal. The department decided to exclude the family planning group from using OpenNotes because of significant concerns over privacy breaches and the impact of that information being shared. Each patient may have a different opinion about the sensitivity of specific topics and this can be difficult for a provider to predict. Therefore, being professional at all times is key. If a sensitive subject is identified in a note, the provider should use terms that clearly explain the what it is, any lab results and what they mean and, if needed, reassure the patient.

BIDMC OB/GYN adopted OpenNotes in 2015 and patients have been largely silent about the transition. In 2016, OpenNotes began a project asking for detailed patient feedback about their notes, beyond a simple patient satisfaction survey. The goal was to understand in more depth the impact that access to visit notes had on patient perceptions of care, the provider and the notes themselves. It also asked patients to elaborate on the causes of their satisfaction or dissatisfaction. Responses are just starting to come in and they are generally positive. Providers are receptive to the feedback and find the positive comments gratifying. The few negative comments were addressed constructively in real-time to quickly repair and strengthen the provider-patient relationship.

“For many providers, the work they put into caring for the patient wasn't obvious; now with OpenNotes patients can see it. This evidence strengthens patients' connections to our providers as their partner in care. Discussion about the visit notes gives a view into what matters to patients beyond what we record about them and this is incredibly valuable for establishing trust. At the end of the day, OpenNotes is good for providers and patients.”

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