Noted: Experimenting with Open Access Notes in Medicine

As health information technology continues to evolve, new and creative uses for electronic health records (EHRs) are beginning to develop. One such “potentially disruptive innovation” is the use of EHRs and patient portals to give patients access to the notes doctors prepare on patients after an office visit. Previously, limited information existed on the effects of giving patients access to visit notes; a team of researchers, led by Tom Delbanco and Jan Walker, set out to remedy this.

The study, published in Annals of Internal Medicine, followed 105 primary care physicians (PCPs) from three different practices and 13,564 of their patients who had access to at least one completed note during the approximately year long intervention. Researchers hypothesized most patients would read the notes and report greater engagement in care and improved management of health, impact on doctors’ work lives would be minimal, and a large percentage of doctors and patients would opt to continue with the intervention, called OpenNotes, after the study ended – these hypotheses were largely shown to be true.

Of the 13,564 patients with visit notes available, 11,797 opened at least one visit note. Unsurprisingly, this was more common for patients seeing a PCP at the two practices with established electronic portals, than it was for patients at the practice where this technology was new and many patients did not own a computer (84 percent and 92 percent versus 47 percent of patients). Forty one percent of patients completed post-intervention surveys, and the results were generally positive across all three practices. The vast majority of patients reported OpenNotes helped them understand their condition, feel more in control of their care, and become more likely to take their medication. Patients’ were most concerned about privacy, with one third citing this as a potential issue. Despite this concern, 99 percent of patients who completed the post-intervention survey wanted to continue receiving access to their visit notes.

For doctors, pre-intervention concerns were largely reduced in the post-intervention surveys. Most doctors reported no increase in the length of the visit or amount of time spent communicating with patients outside of visits. Although some reported taking longer to write their notes, this was sometimes viewed positively, since it led to better documentation. Many doctors believed OpenNotes strengthened patient-doctor relationships and possibly “improved patient satisfaction, patient safety, the ability to reinforce the office visit, and the opportunity for patient education.” No doctor opted to stop the program after the intervention period ended.

Some physicians reported changing the way they addressed sensitive issues, such as mental health, substance abuse, and obesity; suggesting the option to block patient access to selected notes or portions of notes may be helpful. However, doctors’ fears may be deemed unnecessary as few patients reported being concerned by what they read.

The authors of the study do acknowledge limitations – the study population was limited to three geographic regions, all of the practices had already implemented EHRs and patient portals (but nationally, EHR adoption has been uneven), the participating doctors volunteered to be in the study, and survey respondents are generally more positive than non-respondents. Still, the simplicity of the intervention and the many important benefits the researchers found show increased transparency is an important way to improve the patient experience and outcomes at little cost to providers. Tellingly, all three practices have opted to increase patient access to visit notes after reviewing the results of the intervention.

Feature Photo: cc/(Anoto AB)