OpenNotes

OpenNotes organization

OpenNotes is a research initiative and movement located at Beth Israel Deaconess Medical Center focused on making health care more open and transparent by encouraging doctors, nurses, therapists, and other health care professionals to share clinical visit notes (SOAP note) with patients, facilitating patients' legal right to access to their own medical record.[1] Patients who have access to their full medical record, including their notes, report better understanding their diagnosed conditions, feeling more in control of healthcare decisions, and being able to identify errors and inaccuracies in the record.[2]

  • The clinical note is detailed documentation about a medical professional’s encounter with a patient (also known as the SOAP note) and becomes part of a person’s medical record within a given institution. Notes are written by the treating medical provider, but could also be drafted by a medical scribe or medical student and later signed by a board-certified physician.
  • An “open note” is when doctors, nurses other medical professionals share clinical visit notes with patients.[1]
  • U.S. citizens have the legal right to request and receive copies of their medical records, including clinical notes, through the Health Insurance Portability and Accountability Act of 1996 (HIPAA).[3] The process of making a formal medical records request through a hospital can take time and effort, and people must pay for the materials the medical records are delivered on (e.g., paper copies, CDs and DVDs).[4]
  • Sharing clinical notes with patients was made possible more possible after the widespread adoption of electronic health records in the United States and around the world.

Research

In 2010, Beth Israel Deaconess Medical Center in Boston, Geisinger Health System in Pennsylvania, and Seattle’s Harborview Medical Center launched an exploratory study involving 105 primary care doctors inviting 20,000 of their patients to read their clinical notes via secure online patient portals. The study, funded by the Robert Wood Johnson Foundation, examined the effects of sharing notes on both patients and doctors. Results of this study were published in the Annals of Internal Medicine in 2012 in the paper, “Inviting Patients to Read Their Doctors' Notes: A Quasi-Experimental Study and a Look Ahead.”[5] The paper showed that doctors reported little change in workload and clinician fears were unfounded. Patients overwhelmingly approved of note sharing as a practice; few were worried or confused by their notes. Instead, patients reported that reading notes helped them feel more in control of their health and health care. In response, several health systems made plans to adopt open notes. This study has been replicated at numerous sites in the U.S., including at Kaiser Permanente Northwest, Cedars-Sinai, and at the U.S. Department of Veterans’ Affairs, and led to the adoption of sharing clinical notes in North America.

Primary care

Research indicates 25% of patients who contact doctors as a result of reading their notes report possible errors.[6] In a 2012 study,[5] up to 78% of patients reported that reading doctor’s notes helped them take their medications as prescribed. A study by the Geisinger Center for Health Research found patients offered access to notes were more likely to fill their prescriptions for blood pressure medication.[7] A majority of patients reported that reviewing notes made them feel the same or better about their doctor. Research shows that sharing notes with patients can lead to improved communication, collaborative decision-making, and strengthened relationships. 77–87% of patients in one study said that accessing their notes made them feel more in control of their health care.

Caregivers / care partners

In a study,[8] caregivers reported benefits from note sharing similar to those reported by patients. When caregivers are able to review notes (e.g., through a healthcare proxy) they report being able to better manage the health needs of people in their care, including scheduling visits, reconciling medication lists, and following through on recommendations.

Pediatrics and adolescents

Starting at age 13, Boston Children’s Hospital offers parents and patients separate portal accounts so that adolescent children are able to access their open notes.[9] A small study (N=55) of adolescents and young adults (ages 12-20) with chronic pediatric gastrointestinal/liver disease show that in general, AYA's are satisfied with their clinical notes, and all but 1 of the study participants had adequate functional health literacy.[10]

Vulnerable populations

Lower income patients, African Americans and other racial minorities, and those with less than high school education are more likely than white patients or those with higher incomes to report improved trust in their clinician and health care organization when access to notes is offered.[11] When patients read notes, they report benefits, including feeling more comfortable with and in control of medications, having an increased understanding of side effects, and being more likely to take medications as prescribed.[12]

Mental health

Using notes as an integral component of therapy is gaining interest among mental health professionals and patients.[13] Mental health notes are usually written by psychologists, psychiatrists, and social workers. A report from a small sample of Veterans Health Administration patients reading online mental health notes indicates patient experiences are more positive than negative when reading mental health notes.[14] In a study of psychotherapists’ notes shared with patients online at Beth Israel Deaconess Medical Center, results showed, "Nearly all survey respondents (94%) agreed that having open therapy notes is a good idea, and 87% wanted it to continue. More than half reported therapy notes were 'very important'... for feeling in control of their care, trusting their providers and taking care of themselves. Two respondents felt offended, and 7 (11%) felt judged by something they read in a note."[15]

Accuracy of the record

When solicited through an online reporting tool, one-quarter of patients and families receiving care at three different health systems sharing clinical notes in the United States identified potential medical documentation errors, half of which were considered "important" by the patients/families and clinicians.[16] The most common potential inaccuracies included how symptoms were described, past medical history, and the list of medications patients were taking.

Clinician reception

Clinicians (e.g., doctors, nurses) who are considering sharing notes have reported anxiety about sharing notes with patients, including concerns about an increase in workflow, time spent in documentation, and litigation risks (see: medical malpractice and physician burnout). Clinicians who share notes report workflows are not significantly changed, and majority acknowledge that sharing notes is a good idea. More than half of doctors participating in a study[5] felt sharing notes led to improved patient satisfaction and trust.

Health systems sharing visit notes with patients

More than 40,000,000 patients have access to clinical notes at 200 health systems in North America.[17] In 2013, the U.S. Department of Veteran’s Affairs (VHA) introduced an enhanced version of its Blue Button personal health record, including access to clinical notes.

See also

References

  1. Versel, Neil (February 4, 2014). "OpenNotes Helps Keep Patients Informed and Engaged". U.S. News & World Report.
  2. Rabin, Roni Caryn (2012-01-09). "A study encourages people to take the doctor's notes home after exams". The New York Times. ISSN 0362-4331. Retrieved 2019-07-16.
  3. "Health Information Privacy". HHS.gov. 2015-08-26. Retrieved 2019-07-16.
  4. Krumholz, Harlan M.; Campos, Hugo O.; deBronkart, Dave; Mann, Marilyn K.; Hsiao, Allen L.; Daniel, Jodi G.; Gao, Ruiyi; Forman, Howard P.; Lye, Carolyn T. (2018-10-05). "Assessment of US Hospital Compliance With Regulations for Patients' Requests for Medical Records". JAMA Network Open. 1 (6): e183014. doi:10.1001/jamanetworkopen.2018.3014. PMC 6324595. PMID 30646219.
  5. Delbanco, Tom; Walker, Jan; Bell, Sigall K.; Darer, Jonathan D.; Elmore, Joann G.; Farag, Nadine; Feldman, Henry J.; Mejilla, Roanne; Ngo, Long (2012-10-02). "Inviting Patients to Read Their Doctors' Notes: A Quasi-experimental Study and a Look Ahead". Annals of Internal Medicine. 157 (7): 461–470. doi:10.7326/0003-4819-157-7-201210020-00002. ISSN 0003-4819. PMC 3908866. PMID 23027317.
  6. Walker, Jan; Delbanco, Tom; Ralston, James D.; Ngo, Long; Leveille, Suzanne; Elmore, Joann G.; Darer, Jonathan D.; Anselmo, Melissa; Mejilla, Roanne (2017-04-01). "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 Quality & Safety. 26 (4): 262–270. doi:10.1136/bmjqs-2015-004697. ISSN 2044-5415. PMID 27193032.
  7. Walker, Jan; Ngo, Long; Delbanco, Tom; Fossa, Alan; Tusing, Lorraine; Thompson, Jason; Tang, Xiaoqin; Darer, Jonathan; Wright, Eric (2015). "Sharing Physician Notes Through an Electronic Portal is Associated With Improved Medication Adherence: Quasi-Experimental Study". Journal of Medical Internet Research. 17 (10): e226. doi:10.2196/jmir.4872. PMC 4642386. PMID 26449757.
  8. Darer, Jonathan D.; Yule, Christina; Stametz, Rebecca; Green, Jamie A.; Clarke, Deserae; Berger, Andrea; Wolff, Jennifer L. (2016-11-01). "Patients, care partners, and shared access to the patient portal: online practices at an integrated health system". Journal of the American Medical Informatics Association. 23 (6): 1150–1158. doi:10.1093/jamia/ocw025. ISSN 1067-5027. PMID 27026614.
  9. "MyChildrens". apps.childrenshospital.org. Retrieved 2019-07-16.
  10. Huang, Jeannie S.; Yueh, Ryan; Ma, Stacy; Cruz, Rusvelda; Bauman, Laura; Choi, Lillian J. (2019-12-01). "Adolescents' and Young Adults' Satisfaction with and Understanding of Medical Notes from a Pediatric Gastroenterology Practice: A Cross-Sectional Cohort Study". The Journal of Pediatrics. 215: 264–266. doi:10.1016/j.jpeds.2019.06.052. ISSN 0022-3476. PMID 31377044.
  11. Delbanco, Tom; DesRoches, Catherine; Stametz, Rebecca; Shucard, Hannah; Perez, Jocelyn; Payne, Thomas H.; Jackson, Sara; Harcourt, Kendall; Fitzgerald, Patricia (2019). "OpenNotes After 7 Years: Patient Experiences With Ongoing Access to Their Clinicians' Outpatient Visit Notes". Journal of Medical Internet Research. 21 (5): e13876. doi:10.2196/13876.
  12. DesRoches, Catherine M.; Bell, Sigall K.; Dong, Zhiyong; Elmore, Joann; Fernandez, Leonor; Fitzgerald, Patricia; Liao, Joshua M.; Payne, Thomas H.; Delbanco, Tom (2019-05-28). "Patients Managing Medications and Reading Their Visit Notes: A Survey of OpenNotes Participants". Annals of Internal Medicine. 171 (1): 69. doi:10.7326/M18-3197. ISSN 0003-4819.
  13. Delbanco, Tom; Walker, Jan; Bell, Sigall K.; Kahn, Michael W. (2014-04-02). "Let's Show Patients Their Mental Health Records". JAMA. 311 (13): 1291–1292. doi:10.1001/jama.2014.1824. ISSN 0098-7484.
  14. Dobscha, Steven K.; Trevino, Amira; Hooker, Elizabeth R.; Pisciotta, Maura; Denneson, Lauren M. (2019-01-01). "Impacts of a web-based educational program for veterans who read their mental health notes online". Journal of the American Medical Informatics Association. 26 (1): 3–8. doi:10.1093/jamia/ocy134.
  15. O’Neill, Stephen; Chimowitz, Hannah; Leveille, Suzanne; Walker, Jan (2019-07-31). "Embracing the new age of transparency: mental health patients reading their psychotherapy notes online". Journal of Mental Health. 0 (5): 527–535. doi:10.1080/09638237.2019.1644490. ISSN 0963-8237. PMID 31364902.
  16. Bell, Sigall K.; Folcarelli, Patricia; Spencer, Melanie D.; McWilliams, Andrew; Vaden, Tracela; Connor, Crystal D.; Taylor, Yhenneko J.; Davis, Marion E.; Gerard, Macda (2019). "A patient and family reporting system for perceived ambulatory note mistakes: experience at 3 U.S. healthcare centers". Journal of the American Medical Informatics Association. 26 (12): 1566–1573. doi:10.1093/jamia/ocz142.
  17. "OpenNotes notches another big milestone, with 40 million patients now seeing their EHRs". Healthcare IT News. 2019-07-05. Retrieved 2019-07-16.
This article is issued from Wikipedia. The text is licensed under Creative Commons - Attribution - Sharealike. Additional terms may apply for the media files.