COMMENTARY

OpenNotes: Best Practice Tips to Improve Patient Engagement

Gregory R. Weidner, MD

Disclosures

October 31, 2016

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In August 2016, the OpenNotes® movement hit a major milestone, with more than 10 million American patients now able to read their medical notes securely online. This Medscape video series focuses on patient engagement and digital health, so OpenNotes is a great topic to cover in today's installment. I'm Dr Greg Weidner, medical director for primary care innovation and proactive health at Carolinas HealthCare System. Welcome.

Today we will briefly review the history and results of OpenNotes and then provide some practical tips to help you and your practice transition to OpenNotes or make the most out of the opportunity if you are already on the path.

So what exactly is OpenNotes? Patients in the United States have had the right to their medical records since passage of Health Insurance Portability and Accountability Act (HIPAA) in 1996, but the process of getting this access is cumbersome and restrictive. OpenNotes is a national initiative working to give patients electronic access to the visit notes written about their care by doctors, nurses, or other clinicians. In 2010, a 12-month study at three US medical institutions (including over 100 primary care doctors) explored how sharing doctors' notes affected healthcare. Results were published in 2012.[1]

The evidence from this study and others[2] suggests that opening up visit notes to patients makes care more efficient, improves communication, and most importantly may help patients become more actively involved with their health and healthcare.

By reading their notes, patients:

  • Better remember what is discussed during visits;

  • Feel more in control of their care;

  • Are more likely to take medications as prescribed;

  • Feel increased trust in their care;

  • Do not feel confused, worried, or overwhelmed; and

  • Can share notes with their caregivers, better equipping them to stay up to date with visit events and help enact the recommended treatment plan.

By sharing their notes, doctors and other clinicians:

  • Promote patient communication, education, and shared decision-making;

  • Can help patients be better prepared for visits;

  • Can help patients' caregivers optimize care;

  • Can meet patients' overwhelming desire for access to their notes; and

  • Do not report longer visits or more time spent addressing questions outside of visits.

The evidence from the original OpenNotes trial has started a movement to enable patients to easily read notes written about their care and to bring more transparency to medical records.

If your practice or health system is still considering OpenNotes, I highly recommend the resources and toolkit available online, which will help you and your leadership understand the "why" of OpenNotes, anticipate opportunities and challenges, design your program, and manage the change among your providers, staff, and patients. The technology requirements are already in place for most major electronic medical records (EMRs), so the biggest challenges tend to be in the communication process and change management arena. You should speak with representatives from one or more sites already live with OpenNotes to learn about the process and experiences. Careful planning, communication, and a commitment to engaging patients will set you up for success.

Once your patients have access to read their notes, it's important to think about this paradigm shift as you approach your practice and documentation. In an OpenNotes medical world, you should:

  • Be collaborative

    • Include patients in the note-writing process during their visit. This can be as simple as turning the screen to show them what is being recorded. It's a great opportunity to reinforce the findings, discussions, and action plans from the visit.

    • Encourage all patients to read their notes. Reinforce the opportunity to review the visit and revisit discussions and plans.

    • Electronic reminders when a new note is posted increase the open rate of notes.

    • Include hyperlinks to additional resources in your notes (and in patient portal messages), making it easy to explore topics in more depth via recommended online content.

  • Be clear

    • Use simple, direct language. Avoid medical jargon and terminology as well as abbreviations. Your idea of SOB or F/U may not match your patient's.

    • Use formatting to make the notes more readable and comprehensible for patients: use bolded text for important items, increase the font size, and consider placing the Assessment/Plan at the beginning of the note (APSO instead of SOAP).

  • Be concise

    • Attend to accuracy and appropriateness of information included in your notes. Note bloat from pulling in templated data or using copy and paste is a familiar nuisance to all of us who practice in EMR environments. It is even more confusing and frustrating to our patients.

  • Be considerate

    • Discuss what you write, and write what you discuss. Don't let your patient learn about something for the first time when they read their note after the visit.

    • Be factual and complete, but be cognizant about some sensitive topics. Being direct about issues like obesity and substance abuse allows the patient to see those issues in the context of their health (and often respond in positive ways).

    • Use descriptive rather than labeling language to keep things objective.

    • Reinforce positive trends and health behaviors in the note.

It is worth noting that 99% of patients in the original OpenNotes trial wanted OpenNotes to continue. Over 85% of patients said that the availability of OpenNotes would influence their future choice of doctors and health plans.

There is no doubt that we have entered a new era of medical care, characterized by patients who are increasingly engaged and informed and providers who promote collaborative care. OpenNotes is a key foundational element in promoting the transparency, empowerment, and success that our patients desire and deserve. Please use the comments to share your own perspective and experience. We would also love to hear what you think the future holds in relation to OpenNotes or any other facet of patient engagement.

Funding

Initially supported primarily by the Robert Wood Johnson Foundation, OpenNotes is today funded by generous grants from the Robert Wood Johnson Foundation, the Gordon and Betty Moore Foundation, the Peterson Center on Healthcare, and the Cambia Health Foundation, in addition to project-specific grants from CRICO and The Commonwealth Fund of New York.

Resources

Open Notes

Patient EngagementHIT

Suggested Reading

Klein JW, Jackson SL, Bell SK, et al. Your patient is now reading your note: opportunities, problems, and prospects. Am J Med. 2016;129:1018-1021.

Wolff JL, Darer JD, Berger A, et al. Inviting patients and care partners to read doctors' notes: OpenNotes and shared access to electronic medical records. J Am Med Inform Assoc. 2016 Aug 7. [Epub ahead of print]

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