Problem Addressed

• New ways to communicate: Many practices with EMRs offer patients the opportunity to view health information online. For example, patients can often access laboratory test results, medication lists, and other parts of their medical record through secure online systems.^1,2 Some practices also offer secure e-mail to facilitate communication between patients and doctors.³
• Little access to visit notes, despite potential benefits: A review of the personal health records offered by seven large organizations found that none offered patients online access to clinical progress notes.⁴ Yet several studies involving patients with chronic illnesses suggest that access to such notes can be beneficial.¹ One study found that heart failure patients with online access to their medical records had better adherence to treatment recommendations and greater satisfaction with doctor-patient communication.⁵ Another study found that patients with type 2 diabetes who were offered an online collaborative care program (including access to the EMR) experienced greater declines in blood glucose levels than a similar group of nonparticipants.⁶

Description of the Innovative Activity

• Registration for patient portal: To be eligible for the program, adult patients of participating primary care physicians (PCPs) must register to use the patient portal.
• Access to open notes: Any time a participating PCP signs a note following a patient encounter, the EMR system marks the note as "open" unless the PCP designates otherwise (see bullet below). This signature triggers a secure e-mail message to the patient that a note is available for viewing. Patients can access the note by logging in to the patient portal. (Practices without EMRs can give patients a paper copy of the visit note.) Currently, patients can access only those notes written by their PCPs, though the participating sites are reviewing the results from the initial study to determine whether to expand open notes beyond this group.
• Reminder to access note: Two weeks prior to their next scheduled visit, patients receive a second secure e-mail message reminding them to review any notes from the last visit in preparation for their upcoming appointment.
• Multiple uses during care processes: Patients use the information in the notes as they see fit during various care processes. Common uses of the note include (but are not limited to): to remind them of the content of the last visit; to discuss the health and treatment implications of the note (or potential errors in the note) with the doctor during subsequent visits; to share and discuss the note’s contents with family members or other providers; and to act on information or recommendations provided in the note, such as scheduling a followup appointment, adhering to a treatment or lifestyle recommendation, or seeking a second opinion.

References/Related Articles

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Innovator Disclosures

Results

• Very positive feedback from patients and physicians: Post-implementation surveys suggest that both patients and doctors are highly satisfied with the program and have derived multiple benefits from it.⁷
  • Patient-reported satisfaction and benefits: Of those with notes available, 84 percent of Beth Israel Deaconess Medical Center patients and 92 percent of Geisinger Health System patients opened at least one note. At Harborview Medical Center, where patients were using the portal for the first time, 47 percent opened at least one note. A large majority of patients reported benefiting from having access to the notes. Roughly 60 to 80 percent of patients at the three study sites "agreed" or "somewhat agreed" that open visit notes yielded benefits such as facilitating self-care and medication use, increasing their understanding of and control over their health care, and helping them better prepare for visits. Between 20 and 42 percent shared their notes with someone else, usually family members or relatives, and 99 percent of patients wanted to continue having access to their visit notes. In addition, between 86 and 89 percent of patients highlighted the program as being "somewhat" or "very" important to their choice of a doctor or health plan in the future.⁷
  • Doctor-reported satisfaction and benefits, with few downsides: Doctors found participation in the program to be easier than expected and generally did not experience any negative impact on work processes. Only 0 to 5 percent reported longer visits, 0 to 8 percent took more time addressing patients’ questions outside of visits, and 0 to 21 percent reported taking more time writing notes. An analysis of e-mail traffic before and during the trial showed that doctors overall did not receive more messages from patients. The vast majority of doctors (between 85 and 91 percent across the three sites) felt that making visit notes available to patients online was a "good idea," although some felt that the program caused some patients to worry more. In response to an open-ended question about the "best thing" about offering patients access to visit notes, doctors frequently highlighted stronger relationships, better communication, and enhanced ability to engage in shared decision making with patients. Some doctors reported that the program improved patient satisfaction, patient safety, and patient education, including the ability to reinforce topics covered during the office visit. A few reported composing “better notes.” When offered the chance to stop sharing visit notes, none of the participating doctors did.

Evidence Rating (What is this?)

Context of the Innovation

Planning and Development Process

• Securing grant funding and in-house approvals: Delbanco and Walker mounted a multifaceted effort to secure grant funding for the demonstration project. They explained the initiative to representatives of Beth Israel Deaconess's legal department and received clearance to proceed. They also secured institutional review board approval for the research from each of the participating centers.
• Working with information technology (IT) staff to modify EMR: IT staff at each center adjusted the EMR to allow patient access to online visit notes via their patient portals.
• Recruiting participants: Program developers contacted doctors (in individual and group settings) at the three study sites to provide information about the program and invite them to participate. Doctors were given the option to exclude selected patients from the project, but very few did so at Beth Israel Deaconess and Geisinger. At Harborview, doctors excluded many patients suffering with substance abuse and major mental illness.
• Ongoing refinement: Program developers continue to refine the initiative, developing educational tools for doctors and patients, and collaborating with colleagues across the nation. After reviewing their individual results, all three sites have decided to expand the program.

Resources Used and Skills Needed

• Staffing: The effort required few new operational resources, as existing staff incorporate it into their daily routines. Depending on the nature of individual patient portals, IT staff may need to modify the EMR system or patient portal to allow online access to visit notes; at the three participating sites, this process required relatively little time and effort.
• Costs: Each institution spent relatively little on operational costs for the program, since the organizations already had EMR systems in place that could be modified relatively easily. The cost of implementation elsewhere will depend in large part on the current configuration of the EMR system, including whether it already has a patient portal. All three organizations—Beth Israel Deaconess Medical Center with a homegrown EMR, Geisinger Health System with a vendor EMR, and Harborview Medical Center with both—incurred costs to modify their systems.

Funding Sources

Getting Started with This Innovation

• Gauge and attempt to influence views of managers and clinicians: Assess whether the culture of an institution or group of providers promotes transparency and a general willingness to share visit notes with patients. Share publications and highlight experiences from other organizations that demonstrate the potential benefits and risks of doing so.
• Consider merits of clinician "opt in" versus "opt out": In some cases, health systems might want to offer clinicians the option to participate, while institutions with leaders who feel strongly about allowing patient access to visit notes may choose to require clinicians to opt out of the program.
• Develop and approve program-related policies: Those adopting this program need to develop policies about what types of notes should be shared or at times suppressed, which clinicians should participate, and whether and how they might opt out of the system. Policies should be designed, discussed, and approved by medical executive committees, legal departments, or other leadership bodies in the organization, which then need to promote adoption by all providers.
• Consider technical issues: The EMR needs to have a patient portal to support this program. Some systems can be adapted relatively easily to give patients access to visit notes, while others may require significant reprogramming. In the latter instance, clinicians can begin to implement OpenNotes by sharing copies of paper-based visit notes with patients.
• Educate clinicians on writing notes: Given this new transparency, clinicians may need guidance on how to write notes about certain sensitive topics, such as substance abuse, mental health issues, cancer, and obesity.

Sustaining This Innovation

• Cultivate communication between patients and clinicians: As clinicians and patients learn to use this feature effectively, communication about the notes will evolve and in some cases may lead to joint generation of selected notes.
• Market program to public and clinicians: A large majority of patients clearly like the idea of having easy access to information in their medical chart. Consequently, it makes sense to highlight the ability to access visit notes in marketing materials to patients. Such transparency may result in market share gains in a competitive health care market.

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