Overview of Open Notes

Open Notes addresses multiple aspects of diagnostic error reduction including scheduling a referral discussed in a note. It also addresses improving communication between a patient and physician, correcting inaccurate information in the medical record, and asking about concerning lab results and communicating a diagnosis to the patient. Open Notes has been used at multiple institutions.

 

Feasibility/Logistics

Culture: Physicians must be open to allowing patients to easily view their medical records on line- thus some culture of transparency is required.

Usability: There is little learning curve and the process is pretty invisible to physicians once it is implemented but there can be huge resistance to implementation due to physician fears and concerns about creating extra patient anxiety and extra phone or in basket messages. The evidence, however, strongly suggests that the physician concerns of these issues is not born out in practice. Once it is implemented few physicians want to de-implement.

Infrastructure: One needs an EMR and secure patient portal.

Which stakeholders are essential for the tool to be implemented? Physicians and IT are essential for implementation along with good communications to physicians and some resources are needed to be able to trouble shoot any problems or answer any concerns. Legal and risk management may need to be consulted/informed.

 

Implementation

Cost (human and technical): Very low implementation costs.

Location of usage (ambulatory vs. inpatient): Ambulatory setting.

Role out plan: Role out plan can be either all at once or piece meal. There may be some limitations to how piece meal the role out can be depending on the EMR and size of the organization.

 

Post-Implementation Status

Current status (partly adopted or widely adopted): About 20M patients have online access to their notes. [NOTE:This may change overtime so may not be accurate or with recording ]

Limitations: Many patients do not read the Open Notes. If they do read them, they may not properly understand them and/or may not act any differently.

Outcome Measures: Benefits have been measured based mostly on surveys of patients and physicians that indicated they thought Open Notes would be useful and change behavior for the better such that the exact magnitude of the benefit is not known with certainty. Benefits are potentially multiple. There would be better follow up from specialty referrals (patients are more likely to show up to appointments if they know why the referral was made, patients may be able to better articulate to the specialty why the referral was made if the specialist does not have access to the clinic notes and patient may better understand the recommendation of the specialist).

Additional benefits may be patients able to spot errors in their medical record regarding historical information, medications, and allergies. They may become aware of some diagnosis made by their doctor if the physician -patient communication failed. They may see abnormal test results not acted upon by their physician and/or results that the patient was informed about but forgot to follow up on.

Sustainability/Viability: Open Notes has been in use since 2011.

 

References

Sigall KB, Mejilla R, Anselmo M. When doctors share visit notes with patients: a study of patient and doctor perceptions of documentation errors, safety opportunities, and the patient-doctor relationship.BMJ Qual Saf 2017;26:262-270