This article is published in sponsorship with Berkeley Research Group (BRG).
As a recent initiative, a growing number of healthcare organizations are turning to OpenNotes as a strategy for addressing patient engagement shortcomings in the US healthcare system. Originally pioneered by researchers at Beth Israel Deaconess Medical Center (BIDMC), the OpenNotes concept provides patients with complete, unfettered access to copies of their providers’ visit notes. Although initially proposed as a way of improving the accuracy of the data stored within patient medical records, as well as a way of improving patient understanding of the care they are receiving, proponents now cite the benefits of patient engagement as strategically significant in OpenNotes evolution and documented traction across the US.
In an effort to measure potential benefits associated with OpenNotes, the Robert Wood Johnson Foundation (RWJF) funded a small study in 2010 in which 105 primary-care providers shared their visit notes with patients for one year. These patients were asked to complete a survey at the end of the study. Of those that responded, 87 percent indicated that reading their provider’s notes helped them feel more in control of their care, while 60 percent to 78 percent reported an increase in medication adherence. Meanwhile, only eight percent of responding patients reported that the notes caused confusion, worry, or offense.
Based on these early findings, RWJF funded a second, larger two-year study at Geisinger Health System to quantify the benefits, particularly the medication adherence improvements, reported within the BIDMC study. The results of this second study, published in 2015, focused on patients prescribed medication to control blood pressure, but it found only marginal improvements to medication adherence rates.
Public health researchers have also struggled to correlate OpenNotes with significant outcomes improvements or reductions to cost of care. These findings, coupled with the fact that OpenNotes is not tied to any specific reimbursement reform programs, could have meant the demise of the experiment, especially considering apprehension of providers in sharing clinical notes with patients.
However, there have been notable improvements to patient engagement levels within health systems that have rolled out OpenNotes. Nationally, patient portal utilization rates tend to hover in the range of 20 percent to 30 percent, with subtle variations for patient age and provider group size. But BIDMC measured an 84 percent patient portal engagement rate during its OpenNotes project.
These potential improvements in patient engagement levels and improvements to medical record transparency in general prompted the New England Journal of Medicine to publish a call for an expansion to the OpenNotes program, explaining:
Regardless of the setting, open notes can help improve patient safety by allowing contributions from patients and families who may catch questionable statements or clinically important mistakes in notes or find lapses in follow-up that need to be rectified. Indeed, the very existence of an environment in which patients are encouraged to identify potential errors may increase patients’ trust.
To facilitate this expansion, RWJF, in collaboration with Cambia Health Foundation, Gordon and Betty Moore Foundation, and the Peterson Center on Healthcare, recently invested $10 million in OpenNotes with a goal of increasing access to 50 million patients in the next three years. Funding will be used by the OpenNotes program to consolidate best practices and provide strategic support to health systems as they work to reconfigure patient portals to include provider notes and redesign structured provider documentation templates with the patient in mind.
One of the factors to overcome is a well-known issue already plaguing healthcare organizations. Provider notes, serving initially as a means for physicians to share their thought process with colleagues on the care team, also play a key role in substantiating reimbursement claims for the visit. To support these multiple uses, electronic health record (EHR) systems seek to streamline the provider workflow by prepopulating information necessary for reimbursement, but which might be unrelated to the clinical thought process. This can result in a final note that many providers complain is unnecessarily long and cluttered with redundant or frivolous information. Known colloquially as “note bloat,” the impact EHR systems have had on the readability of provider notes is a well-documented point of dissatisfaction for physicians.
Before health systems can safely move forward with an OpenNotes pilot project, “note bloat” concerns within the organization must be analyzed and rectified. For an OpenNotes pilot to generate meaningful improvements to patient engagement, the shared notes must be coherent and logically structured. To accomplish this, existing provider documentation templates need to be thoroughly reviewed with the patient in mind. Provider roundtable discussions and template enhancement efforts will yield redesigned notes that are not only appropriate for the patient but also resolve “note bloat” dissatisfactions within the provider community.
Provider education is also a major undertaking in the transition to an OpenNotes organization. While template redesign is imperative, physicians will also need to consider, at the point of documentation, that the narrative they include in their note will be shared and eventually read by the patient. Many EHR systems can be configured to present reminders or instructions within the provider documentation workflow that are not included in the final output of the note. By educating providers on documenting in an OpenNotes environment, and then supplementing that education by enhancing the provider workflow with embedded guidance, health systems can position their clinical teams for a positive OpenNotes transition.
As reimbursement models continue to shift toward value-based arrangements and regulatory requirements continue to prioritize patient engagement efforts, OpenNotes is gaining traction across the country. The transition to OpenNotes requires a detailed review of existing structured templates and provider documentation workflows and a comprehensive physician education plan.
Health systems thinking about making such a transition would be joining a growing number of other reputable organizations that have already made the transition, including BIDMC, Cleveland Clinic, MD Anderson Cancer Center, Wake Forest Heath, all Veterans Affairs Medical Centers, and many more.
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