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Service Delivery Innovation Profile

Online Patient Access to Visit Notes Generates Positive Early Reviews From Patients and Primary Care Physicians


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Snapshot

Summary

More than 100 primary care doctors and 20,000 patients at Beth Israel Deaconess Medical Center in Boston, Geisinger Health System in Pennsylvania, and Harborview Medical Center in Seattle participated in a 12-month demonstration project of OpenNotes®, a program where doctors invite patients to access their notes detailing medical office visits via a secure patient portal linked with their electronic medical record system. Registered portal users receive an automatic e-mail notification after their doctor signs a note from a visit. They can access the note by logging in to the portal, using it as they see fit. For example, patients may read a note to develop a better understanding of their care; discuss aspects of the visit with the doctor at the next office visit; act on self-management, treatment, and other recommendations included in the note; and share the note with others, including family members and other providers. The program has generated high levels of satisfaction and produced multiple benefits for both patients and doctors.

Evidence Rating (What is this?)

Suggestive: The evidence consists of post-implementation surveys of patients and physicians about their perceptions of the OpenNotes program and analysis of electronic records of patients’ portal use and outpatient visits.
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Developing Organizations

Beth Israel Deaconess Medical Center; Geisinger Health System; Harborview Medical Center
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Use By Other Organizations

In May 2009, M. D. Anderson Cancer Center began allowing patients to access visit notes, including its many patients who come from across the United States and around the world; feedback from both doctors and patients has been overwhelmingly positive.8

Information provided in October 2013 indicates that in early 2013, the Department of Veteran Affairs (VA) granted its 1 million-plus MyHealtheVet portal users access to notes. The VA continues to advocate for patient access to data.9 

Information provided in October 2013 also indicates that the Cleveland Clinic announced in June 2013 that patients will be given access to their physicians' notes by 2014.10 

Date First Implemented

2010
Summer

Problem Addressed

Electronic medical records (EMRs) and other information technologies provide new ways for doctors and patients to communicate effectively and efficiently. Secure patient portals can give patients access to test results, medication lists, and other parts of the EMR. Yet few provider organizations have leveraged such technologies to offer patients online access to visit notes, even though doing so could be beneficial to patients.
  • 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

What They Did

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Description of the Innovative Activity

Patients access their doctors' notes from medical office visits via a patient portal linked with the EMR system. Two weeks prior to subsequent scheduled visits to their doctor, they also receive an e-mail reminder suggesting that they review previous notes. Patients access the notes by logging in to the portal and then use the notes as they see fit during various care processes, such as discussing them with the doctor at the next office visit; acting on self-management, treatment, and other recommendations included in the notes; and sharing the content with family members and other providers. Key elements of the system include the following:
  • 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.) During the study, patients were only able to access those notes written by their PCPs. Information provided in October 2013 indicates that the participating institutions are in the process of expanding access to visit notes to more patients, as well as branching beyond primary care practices.
  • Reminder to access note: Two weeks before 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 notes include but are not limited to the following: 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 notes' contents with family members or other providers; and to act on information or recommendations provided in the notes, such as scheduling a followup appointment, adhering to a treatment or lifestyle recommendation, or seeking a second opinion.

Context of the Innovation

The Beth Israel Deaconess Medical Center is a 631-bed academic medical center affiliated with Harvard Medical School. The medical center's primary care practice, Healthcare Associates, serves 40,000 patients and handled more than 100,000 visits in 2010. The medical center also has many PCP offices located throughout the Boston metropolitan area. Geisinger Health System is a large, doctor-led integrated health care delivery system operating in central and northeastern Pennsylvania. The system includes three hospitals on two campuses (a closed-staff hospital in Danville and a two-hospital campus in the Scranton-Wilkes Barre area); the Geisinger Clinic, with more than 750 physicians; and the Geisinger Health Plan, which provides coverage to approximately 220,000 enrollees. The 413-bed, county-owned Harborview Medical Center serves as the main teaching hospital for the University of Washington School of Medicine, handling more than 246,000 clinic visits annually.

This program grew out of Beth Israel Deaconess Medical Center's long-time involvement in patient-centered care, including founding the Picker Commonwealth Program for Patient-Centered Care (later known as the Picker Institute), being involved in the development of the Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys, and being an early adopter of EMRs (first introduced in the late 1980s) and an online patient portal (in 2000). This portal, known as PatientSite, allows patients to access diagnostic test results, medication lists, and educational materials; schedule appointments; and send secure e-mails to providers.

The impetus for this specific program came from two individuals—Tom Delbanco, MD, founder of the hospital's Division of General Medicine and Primary Care, a founder of the Picker Institute, and a researcher, educator, and PCP who has practiced at Beth Israel Deaconess Medical Center for 40 years; and Jan Walker, RN, MBA, a health services researcher and former director of the Picker Institute's survey services who has a long-time interest in patient-centered initiatives. Dr. Delbanco had been sharing paper-based medical notes with his patients since the 1980s, and he and Ms. Walker felt that it made sense to expand the portal's functionality to allow patients to view such notes online.

Did It Work?

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Results

The program has generated high levels of satisfaction and produced multiple benefits for both patients and doctors. Feedback in post-implementation surveys has been very positive, suggesting 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 decisionmaking 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?)

Suggestive: The evidence consists of post-implementation surveys of patients and physicians about their perceptions of the OpenNotes program and analysis of electronic records of patients’ portal use and outpatient visits.

How They Did It

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Planning and Development Process

Selected steps included the following:
  • Securing grant funding and in-house approvals: Dr. Delbanco and Ms. 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.
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Funding Sources

Robert Wood Johnson Foundation's Pioneer Portfolio; Drane Family Fund; Koplow Charitable Foundation
The Robert Wood Johnson Foundation's Pioneer Portfolio served as the primary funder of this program.end fs

Adoption Considerations

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Getting Started with This Innovation

  • Gauge and attempt to influence views of managers and clinicians: It is important to assess whether the culture of an institution or group of providers promotes transparency and a general willingness to share visit notes with patients. Related views can be influenced by sharing publications and highlighting 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.

Use By Other Organizations

In May 2009, M. D. Anderson Cancer Center began allowing patients to access visit notes, including its many patients who come from across the United States and around the world; feedback from both doctors and patients has been overwhelmingly positive.8

Information provided in October 2013 indicates that in early 2013, the Department of Veteran Affairs (VA) granted its 1 million-plus MyHealtheVet portal users access to notes. The VA continues to advocate for patient access to data.9 

Information provided in October 2013 also indicates that the Cleveland Clinic announced in June 2013 that patients will be given access to their physicians' notes by 2014.10 

More Information

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Contact the Innovator

Tom Delbanco, MD, MACP
Koplow-Tullis Professor of General Medicine and Primary Care
Harvard Medical School
Division of General Medicine and Primary Care
Beth Israel Deaconess Medical Center
330 Brookline Avenue
Boston, MA 02215
(617) 754-1454
E-mail: myopennotes@bidmc.harvard.edu

Jan Walker, RN, MBA
Principal Associate in Medicine
Harvard Medical School
Division of General Medicine and Primary Care
Beth Israel Deaconess Medical Center
330 Brookline Avenue
Boston, MA 02215
(617) 754-1454
E-mail: myopennotes@bidmc.harvard.edu

Innovator Disclosures

Dr. Delbanco and Ms. Walker reported receiving grant funding and travel-related support for this program from the Robert Wood Johnson Foundation; additional information on funders is available in the Funding Sources section.

References/Related Articles

Delbanco T, Walker J, Bell SK, et al. Inviting patients to read their doctors' notes: a quasi-experimental study and a look ahead. Ann Intern Med. 2012;157(7):461-70. [PubMed] Available at http://annals.org/article.aspx?articleID=1363511.

Delbanco T, Walker J. Benefits from destroying the black box (or are we opening Pandora’s box?). SGIM Forum. 2012;35(2):1-2. Available at http://www.sgim.org/File%20Library/SGIM/Resource%20Library/Forum/2012/Feb2012-02.pdf (If you don't have the software to open this PDF, download free Adobe Acrobat ReaderĀ® software External Web Site Policy.).

Delbanco T, Walker J, Darer JD, et al. Open notes: doctors and patients signing on. Ann Intern Med. 2010;153(2):121-5. [PubMed]

Dhanireddy S, Walker J, Reisch L, et al. The urban underserved: attitudes towards gaining full access to electronic medical records. Health Expect. 2012; Jun 28. [PubMed]

Feeley TW, Shine KI. Access to the medical record for patients and involved providers: transparency through electronic tools. Ann Intern Med. 2011;155(12):853-4. [PubMed]

Goldzweig CL. Pushing the envelope of electronic patient portals to engage patients in their care. Ann Intern Med. 2012;157(7):525-6. [PubMed]

Leveille SG, Walker J, Ralston JD, et al. Evaluating the impact of patients' online access to doctors' visit notes: designing and executing the OpenNotes Project. BMC Med Inform Decis Mak. 2012;12:32. [PubMed]

Meltsner M. A patient’s view of OpenNotes. Ann Intern Med. 2012;157(7):523-4. [PubMed]

Walker J, Leveille SG, Ngo L, et al. Inviting patients to read their doctors’ notes: patients and doctors look ahead: patient and physician surveys. Ann Intern Med. 2011;155(12):811-9. [PubMed]

Additional information about the OpenNotes project, including links to videos and news stories, is available at: http://www.myopennotes.org.

Footnotes

1 Walker J, Leveille SG, Ngo L, et al. Inviting patients to read their doctors’ notes: patients and doctors look ahead: patient and physician surveys. Ann Intern Med. 2011;155(12):811-9. [PubMed]
2 Pagliari C, Detmer D, Singleton P. Potential of electronic personal health records. BMJ. 2007;335(7615):330-3. [PubMed]
3 Ralston JD, Martin DP, Anderson ML, et al. Group health cooperative's transformation toward patient-centered access. Med Care Res Rev. 2009;66(6):703-24. [PubMed]
4 Reti SR, Feldman HJ, Ross SE, et al. Improving personal health records for patient-centered care. J Am Med Inform Assoc. 2010;17(2):192-5. [PubMed]
5 Ross SE, Moore LA, Earnest MA, et al. Providing a Web-based online medical record with electronic communication capabilities to patients with congestive heart failure: randomized trial. J Med Internet Res. 2004;6(2):e12. [PubMed]
6 Ralston JD, Hirsch IB, Hoath J, et al. Web-based collaborative care for type 2 diabetes: a pilot randomized trial. Diabetes Care. 2009;32(2):234-9. [PubMed]
7 Delbanco T, Walker J, Bell SK, et al. Inviting patients to read their doctors' notes: a quasi-experimental study and a look ahead. Ann Intern Med. 2012;157(7):461-70. [PubMed] Available at http://annals.org/article.aspx?articleID=1363511.
8 Feeley TW, Shine KI. Access to the medical record for patients and involved providers: transparency through electronic tools. Ann Intern Med. 2011;155(12):853-4. [PubMed]
9 Department of Veterans Affairs. New VA Blue Button features for 2013: VA notes, VA CCD and more. 2013 Apr 1. Accessed at http://www.va.gov/bluebutton/.
10 Cleveland Clinic.  Cleveland clinic making electronic medical records more transparent to patients online. 2013 June 6. Available at http://my.clevelandclinic.org/media_relations/library/2013
/2013-06-06-cleveland-clinic-making-electronic-medical-records-more-transparent-to-patients-online.aspx
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Original publication: October 10, 2012.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: October 23, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.