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Researchers at Beth Israel Deaconess Medical Center Examine the Impact of OpenNotes on Patient Safety

Patient engagement through reading visit notes holds promise

BOSTON – Researchers from Beth Israel Deaconess Medical Center (BIDMC) are homing in on the potential benefits of allowing patients access to the notes their clinicians write after a visit. An article published in the August edition of The Joint Commission Journal on Quality and Patient Safety suggests that this kind of patient engagement has the power to improve safety and quality of care.

The practice of sharing visit notes more readily began with the OpenNotes study in 2010. More than 100 primary care doctors at three hospitals invited 20,000 of their patients to read their visit notes through a secure, patient website. Patients reported feeling more in control of their health, being better prepared for their visits and several other benefits. Doctors saw little or no impact on their work flow. In the five years since the launch of the study, the number of patients who are able to read their visit notes has grown to more than five million nationwide.

The researchers drew from five years of experience with OpenNotes, new survey data and focus groups to examine key areas of patient safety and quality of care that might be impacted by more open communication between doctors and patients.

“What we heard from patients and doctors fell into recognizable categories – for example, catching medication errors, better remembering next steps and improved plan adherence, enhanced error reporting, improved coordination of care for informal caregivers of vulnerable patients with many providers and appointments, and reduced diagnostic delay. In many common safety categories, it appears that having the patient’s or an informal caregiver’s eyes on clinical notes can help ensure care is safer. Doctors review hundreds or thousands of charts; patients review one: their own,” says lead author Sigall Bell, MD, in the Division of General Medicine and Primary Care and Assistant Professor of Medicine at Harvard Medical School. “OpenNotes may have a unique role in connecting patients and clinicians in the space between visits.”

Patients said, among other things, that their doctors’ notes helped them remember to take their medications better and recall more of what happened during office visits. Some noticed errors in their records that were subsequently corrected. Others read the notes and were reminded to follow up on clinically significant appointments.

“These are all examples of patients who used the notes to engage in their own health care and to play active roles in making their care better,” says Bell. “The message that we are getting from many patients is that they want to participate in their care. And while the responsibility for patient safety still rests primarily with health care organizations, this research shows us what’s possible when we make space at the table for patients.”

Doctors could also see the promise of sharing visit notes with patients. One doctor wrote, “I felt like my care was safer, as I knew the patients would be able to update me if I didn’t get it right.”

While both patients and doctors showed enthusiasm, some doctors also expressed concerns. They wondered if note writing would become more vague knowing that patients would be reading the notes. The doctors also worried about how patients would define mistakes, how patients would report errors and ultimately, how that process might impact trust.

“We understand that these are real concerns that need to be addressed with education, innovation, and further research,” says Bell. “But, we think solutions can be reached. Data suggest that transparent communication can enhance trust, and that activated patients have better experiences of care. The benefits of partnering with patients in this way are likely well worth the effort.”

Bell and colleagues are using this preliminary research to guide work on a two-year study – The OpenNotes Patient Safety Initiative – funded by CRICO, a hospital insurance provider. The initiative will examine the impact of note sharing on patient safety, medical errors and communication with the goal of further developing and refining an online reporting tool for patients to provide feedback on their notes.

The researchers have been piloting a prototype of the patient reporting tool with a set of volunteering clinicians at HealthCare Associates, BIDMC’s primary care practice. Based on results to date from this pilot program, CRICO recently provided additional funding to bring the OpenNotes Safety Initiative more broadly to BIDMC and to Boston Children’s Hospital.

In addition to Bell, researchers include; Patricia H. Folcarelli, RN, PhD, Melissa Anselmo, MPH, Bradley H. Crotty, MD, MPH, Lydia A. Flier and Jan Walker, RN, MBA of BIDMC.

Beth Israel Deaconess Medical Center is a patient care, teaching and research affiliate of Harvard Medical School and consistently ranks as a national leader among independent hospitals in National Institutes of Health funding.

BIDMC is in the community with Beth Israel Deaconess Hospital-Milton, Beth Israel Deaconess Hospital-Needham, Beth Israel Deaconess Hospital-Plymouth, Anna Jaques Hospital, Cambridge Health Alliance, Lawrence General Hospital, Signature Healthcare, Beth Israel Deaconess HealthCare, Community Care Alliance and Atrius Health. BIDMC is also clinically affiliated with the Joslin Diabetes Center and Hebrew Senior Life and is a research partner of Dana-Farber/Harvard Cancer Center and The Jackson Laboratory. BIDMC is the official hospital of the Boston Red Sox. For more information, visit www.bidmc.org.