Physicians

The OpenNotes Toolkit

In writing about OpenNotes last summer, I argued that the practice of sharing clinicians’ notes with patients had moved beyond the question of whether it was a good idea (the landmark study published in Annals of Internal Medicine was pretty clear on that) to questions of how best to implement it.

As more organizations adopt the practice, it’s clear that we’re now in a phase of implementation, and experimentation with different approaches and learning.  Tom Delbanco, MD, one of the project leads, often compares open notes to a drug — it does have some side effects and some contraindications for some people and some circumstances — and we all need to understand those nuances.

To make it easier for health care organizations to offer the service to their patients, the OpenNotes project team has just released a new toolkit.

The toolkit focuses on two challenges:  helping organizations make the decision to implement open notes and helping organizations with all the steps involved in implementing open notes.

It includes a slide deck that lays out the results of the study and makes the case for implementation, a video profile of how a patient and her doctor have used the practice, profiles of the implementations at the pioneering sites, FAQs for clinicians and patients, and tips for clinicians on how to write open notes.

Please check it out and tell the OpenNotes team what you think:  is it valuable? How could it be better?


In a recent perspective piece in the New England Journal of Medicine, OpenNotes study leaders Jan Walker, Jon Darer, Joann Elmore and Tom Delbanco write that they anticipate that providing open notes will become the standard of care.

With institutions like Beth Israel Deaconess Medical Center, Geisinger Health System, Cleveland Clinic, Mayo Clinic, the VA Health System and several others offering open notes, they estimate that two million people now have access to the notes their physicians write about them.

The deliberations of the HIT Policy Committee are also revealing:  while the committee declined to make the provision of open notes a requirement under Meaningful Use Stage 3, their report indicates that they gave the idea serious consideration and only held back because they felt it was too early to prescribe the method for implementing open notes.

In short, there’s an increasing sense that opening up clinician notes to patients is inevitable.  It’s our hope that the new toolkit will make it easier for all who are curious about the practice to assess the idea, sell the idea, and bring it to fruition.

Steve Downs (@stephenjdowns) is the Senior Technology and Information Officer, Robert Wood Johnson Foundation.

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ข้อสอบข้อเขียนbalacSarah MartinRobe-Patient DaveCarolyn Thomas Recent comment authors
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ข้อสอบข้อเขียนbalac
Guest

I am truly thankful to the holder of this website who has shared
this enormous article at at this time.

Sarah Martin
Guest
Sarah Martin

As a patient I think the Open Notes program is outstanding. I have just
returned from a week in the hospital. Both I and my daughter are extremely pleased to be able to learn every day the results of tests done the day before whether good or bad. There is no speculation about the future in the notes I have seen. But by reading the notes I can prepare questions based on the actual facts to discuss with the doctor when we meet.

Rob
Guest
Rob

The last two comments, in my opinion, together sum up the most importat points in this discussing: that we as physicians work for our patients, and that the medical record is not our stage on which to perform, but rather are a place of opportunity to communicate information that will enable our patients to get the best possible care. We serve. The patient is not just something for us to write about; they are, and should always be, the reason anything is done in the exam room and in the record. Well done, Peter and Sandra!

Saurabh Jha
Guest
Saurabh Jha

It’s hard to refute anything you have said because they are truisms. Except they do not apply to open notes in particular but communication in general. In that case you make my argument far more eloquently than I do.

Saurabh Jha
Guest
Saurabh Jha

I agree that its better to have more ideas and more failures than fewer ideas and fewer successes. Hopefully, one realizes in the set up that any one idea is more likely to fail than succeed, and success is the signal that emerges from a plethora of noise. So yes, it’s good the value of open notes has been systematically analyzed. This is only one part of the scientific rigor. The next part should not be avoided just because the results were published in a high impact paper or the arguable self-evidence of the proposition. Thanks for quoting Carl Sagan,… Read more »

Peter Elias
Guest

I doubt that Sagan would disapprove of my use of his phrase. Regardless, there is certainly overlap if not convergence in our approaches. Interesting null hypothesis you pose, with four parts – so really four hypotheses. 1. Could have unintended consequences. I actually see this as a given. The issue is just what they are. 2. Increase paperwork. Aside from the fact that in my work we would be talking about increasing keyboard work, this is testable and should definitely be tested. Based on my experience, it does increase work. If we could measure the increase, it would be easier… Read more »

Saurabh Jha
Guest
Saurabh Jha

Your statement is a moral not scientific one. That doesn’t mean Carl Sagan would disapprove. But his approval would not blur the distinction.

Outcomes are fairly simple. Reduce morbidity and mortality. Standard for any intervention.

Remember the onus is on you to show that your innovation works not on me to prove that it doesn’t.

Leslie Kernisan, MD MPH
Guest

Actually, outcomes are not simple. This is esp true for frail older adults, but I’m sure it’s true for younger patients as well. Part of the problem with healthcare is that we’ve historically let doctors dictate what outcomes matter. Often doctors shower medications on patients, because there is supposedly a mortality and morbidity benefit. OpenNotes and other aspects of participatory medicine can help us shift to an environment in which we agree on goals with our patients, and give them lots of opportunites to realign care with their needs and preferences. I do think you’ve raised interesting points, but as… Read more »

Sandra Raup
Guest

“Reduce clinical honesty.” I’d like to hear a definition of the honesty involved. Do you mean patients would be less honest? I’ve heard clinicians suspicious of their patients’ honesty. Do you mean clinicians being less honest? If so, why would that be? I expect more honesty if I can review the documentation. That’s the case with any bill I receive, and with my financial accounts. And what’s the purpose of either patients or clinicians not being honest?

Peter Elias
Guest

Sandra -> I didn’t mean to be cryptic about honesty. My experience (which is just that – my experience) is that writing notes that represented my private take on the interaction was associated with a form of (benevolently intended) dishonesty that was obvious once I started writing my notes ‘out loud’ with patients. It allowed – encouraged – me to have lots of thought and opinions that I never shared, but too frequently acted on. Now, I tend to document as the ‘public record’ only those things that are public, in the sense of available both to me and the… Read more »

Sandra Raup
Guest

Peter, Yes I know what you meant – I was calling this out (hopefully not in a critical way). A few months ago I spoke to a former colleague who said they now had a system for sharing notes with patients but they can “hide” notes if they think it’s appropriate. I know what clinicians mean, but I think it’s more an artifact of the past (i.e., traditional roles) than something that really makes sense. When I was working in a clinical setting, I sometimes cringed at descriptions of patients, especially elderly women. I thought it was unnecessary, not even… Read more »

Saurabh Jha
Guest
Saurabh Jha

Clinicians and their clinical honesty about the assessment of the patient. Just because you don’t see a purpose to lack of honesty doesn’t guarantee that honesty will occur.

It’s like saying “I see no reason why anyone would attack you at 2 am in the morning in a lonely street so you are perfectly safe.”

The prevalence of unintended consequences is not contingent of your imagination ,

Sandra Raup
Guest

You are absolutely right. I just think it’s a bit “old school” to say that patients should be subject to it. Maybe we’ve gone too far with autonomy in this country – perhaps people “can’t handle the truth”. It will be interesting to see how it all plays out.

Saurabh Jha
Guest
Saurabh Jha

“I love the idea of bringing some academic rigor to the issue, but I am not optimistic. Not everything that counts can be measured and not everything that can be measured, counts.” That is correct. I cannot offer an answer that covers all eventualities except to say that one must use judgment (or Bayesian analysis if you want to sound fancy) when asking on whom the burden of proof lies. My usual rule, certainly not 100 % water tight, is that the burden of proof (and study design and accompanying type 1 and type 2 errors) lies on those who… Read more »

Peter Elias
Guest

“My usual rule, certainly not 100 % water tight, is that the burden of proof (and study design and accompanying type 1 and type 2 errors) lies on those who purport to change.” It is hard to disagree with this, as long as one remembers that most medical care issues are neither simple nor even complicated, but complex, and therefore *by definition* not predictable in advance. Learning and progress happen only if and when multiple trials of multiple variations in multiple settings occur, and the results are studied. To me, this translates into: “It looks and sounds as if there… Read more »

William Palmer MD
Guest
William Palmer MD

Most docs are busy. We are not running adolescent psychiatry counseling sessions that last three hours with juice. When I was in the Air Force and was the medical officer of the day, I had so many airman in my waiting room that I had to immediately triage. “People who think they have a fever, stand over there.””People who are coughing, move to the back.” Then my NCOs would proceed with the thermometers, white counts, etc. You get the picture. I don’t mind showing my patients what I have written. They can add subtract or correct. But we simply can’t… Read more »

Saurabh Jha
Guest
Saurabh Jha

Well said. Certainly said better than my rants!

Peter Elias
Guest

I love the idea of bringing some academic rigor to the issue, but I am not optimistic. Not everything that counts can be measured and not everything that can be measured, counts. For example, I would speculate (hypothesize) that taking and recording a history with the premise that it is a collaborative process to develop a shared working document and plan rather than my private memoir of the interaction and my intent would make the history both more accurate and more actionable. That’s how it feels subjectively. Slightly more objectively, reading my notes from 5 years ago and from 3… Read more »

Peggy Kriss
Guest

I am a clinical psychologist using Open Notes in an outpatient mental health setting for the past year. I start each session reviewing our notes from the previous session, and leave time in our session at the end to TOGETHER write our note for the session. As my clients get more used to the system, they often ask me in the middle of a session to please add a certain comment by a client or me- an important insight, etc. At the end of the session, I often ask a client to summarize the session and I will write down… Read more »

Peter Elias
Guest

I am not a clinical psychologist, but as a family physician, I find that I do a huge amount of work with patients on psychological issues and problems related to their living circumstances, and that there is no clear division between these issues and more clearly medical issues like hypertension or congestive heart failure. (Or even strep throat.) I am thrilled to hear your description of your approach, because it fits so well with my experience. My approach to patients aims to be as collaborative as I can manage. I believe that my patients are absolutely entitled to understand not… Read more »

Rob
Guest

Agree. I think there will clearly be a segment of the physician population who will resist the collaborative approach to care (and the requisite sharing of data for collaboration) out of reflex. We’ve fallen far, first from the time when our knowledge of facts was special. Patients have quick access to all of the facts I know as a doctor. Docs still resent patients who check Google before calling us (even though most do). We are now falling from our “keepers of the tome” of the health record, and sharing the decision-making with the patient. More and more, docs are… Read more »

The OpenNotes team
Guest

Thank you for joining this discussion, Dr Kernisan. As with other contributors to this discussion, we take your insights to heart! To address your questions: Right now we’re preparing to examine the experiences of far broader groups of patients and clinicians (extending well beyond primary care), and starting also to explore the implications of shared visit notes for areas such as mental health, patient safety and medical errors, medication refills, caregiver issues, and educational opportunities for medical students and trainees. We’re also looking back at our patient cohort to better understand co-morbidities among patients choosing to read notes. With respect… Read more »

Leslie Kernisan, MD MPH
Guest

I’m overall for OpenNotes, largely for the reasons that Rob and Peter Elias mention above. I even got my EMR developer to enable it for me (thank you Ben at MD-HQ!) so now all my geriatric consultation notes are available to the family members or geriatric care managers who access the patient portal. Major caveats: 1. My practice being what it is, virtually all of my patients are impaired or otherwise have their care being overseen by someone else. In other words, I’m currently spared from worrying about what my patients themselves think when I assess their abilities and health… Read more »

Steve Downs
Guest
Steve Downs

I’ve enjoyed watching this debate unfold over the past few days. Debate is healthy and when the debate is over changes that affect the fundamental nature of the patient-physician relationship, it’s really important. I find the concerns that have been raised in the comments to be real, valid and quite familiar. They are the concerns and the questions that any thinking and caring physician should have. As Dr. Delbanco and Ms. Walker note, the practice of opening up notes is not for everyone and not for all circumstances. Learning about those nuances and how best to implement OpenNotes — so… Read more »

Saurabh Jha
Guest
Saurabh Jha

” Some luddites out there are fearful of patients seeing this reality, to be sure” To be sure your statement is likely to be correct but it should not lead one to the logical fallacy of affirming the consequent (luddites are skeptics therefore skeptics are luddites). “I somehow feel that suggesting this requires “rigorous study” seems like the smoke screen which comes from reluctance to engage the patient in the process” It may be but rigor is a discipline that survives its motivation. “All I can say is that the more I’ve engaged patients in the process, the more open… Read more »

Rob
Guest

I do wonder if doctors fear if patients see the records they will realize how terrible they often are. Some luddites out there are fearful of patients seeing this reality, to be sure. I find my patients quite happy to participate in improving the quality of their documentation and getting that information for their own use with other providers. It is their record. It is their health that is at stake. Unfortunately, most records are only viewed when there are problems bad enough for the patient to come in for care. I somehow feel that suggesting this requires “rigorous study”… Read more »

Saurabh Jha
Guest
Saurabh Jha

Several points made are notable and convincing arguments that there is a problem but none that cannot be solved by the following: – thorough and targeted history, and physical exam which physicians should be doing ( if you’re missing the right nephrectomy on history then it is not thorough enough) – succinct communication between physicians. Whatever happened to the “Dear Dr. Overworked, thank you for referring this delightful 88 year old caucasian lady with long standing history of epigastric pain”? Open notes seems to generate in physicians a feeling of warmth and fuzziness. Fair enough. Nothing wrong with that. Oh… Read more »

Peter Elias
Guest

There has been lots of philosophy, conjecture and personal opinion on display here. I would like to offer a practical experience. I had been in the habit of providing a copy of my office visit note to selected patients, primarily those with complex problems who were going to be seeking part of their care outside our system. I am now nine months into giving a copy of my note to every patient I sed. I believe there have been three exceptions during that time – all three related to patients with issues of sexually transmitted infections whose partners were waiting… Read more »

William Palmer MD
Guest
William Palmer MD

@Delbanco and Walker Are the early adopters using OpenNotes for psychiatry and psychology notes? Are they using ONs for drug rehab? When they are using ONs, are both docs and patients mutually agreeing on their use in a care contract? Are they getting appropriate committee notes–ones that have reviewed the patient’s care (e.g., the internal medicine committee, the infection committee, the utilization committee, etc.)? If not, why? These are quasi-providers themselves. Are they reviewing and opening up other appropriate provider notes? E.g pharmacy; nursing; PT, OT, dental? If not, why? If there is a discusssion in the Board meeting of… Read more »

Peter Elias
Guest

You asked lots of questions, but this one stood out for me because of a recent experience: “Do you believe that patients are unable to view their charts generally, today? What is wrong with the current system? Legal request ==>chart copied==token payment==>receipt of record.” I recently cared for a single mother of 3 children under the age of 10, two of whom have some complicated medical illnesses, one of which may turn out to be an inheritable metabolic disorder. Our local community is not really able to meet all the family needs. She quite legitimately asked for copies of all… Read more »