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November/December 2019

Chart Conundrums: OpenNotes — What We’ve Learned So Far
By Catherine M. DesRoches, DrPH, and Liz Salmi
For The Record
Vol. 31 No. 10 P. 8

The transparency movement known as OpenNotes has been encouraging hospitals, health systems, and individual clinicians to share clinical notes with patients since 2012. Today, more than 40 million patients have access to clinical notes through online patient portals at more than 200 health systems throughout North America. Currently, there are close to 100 papers published on the topic of open notes. And the namesake organization has more than five years of experience working with and learning from real-world implementations.

No organization is forced to share clinical notes, but new rules proposed by Health and Human Services and the Office of the National Coordinator for Health Information Technology are placing a strong focus on patients’ ability to access their health information.

The rules propose clinical notes be included in an expanded set of data that must be electronically exchanged between health care organizations and made easily accessible to patients. These concepts, as well the growth of consumer-friendly health technology platforms, are leaving HIM professionals wondering what they need to be prepared for in case access to notes does indeed become the law of the land.

With that in mind, here are several key facts HIM professionals should know as the practice of note sharing spreads and potentially becomes a mandate in the United States.

Who Is Behind OpenNotes?
OpenNotes is not software, a technology vendor, or a lobbying organization. Based at the nonprofit Beth Israel Deaconess Medical Center in Boston and sustained by philanthropic support, OpenNotes works with collaborators around the country and overseas to evaluate the spread and effective implementation of shared clinical notes with patients.

The organization, which studies the effects of this practice on patients, care partners, and clinicians, disseminates its findings.

What Does the Research Say About OpenNotes?
Research and implementation experiences demonstrate that easy access to ambulatory notes brings substantial benefits to patients.

Patients, parents, and care partners report many important clinical benefits from reading open notes, including a better understanding of their health conditions; feeling more in control of their care; better recall of the content of visits; improved adherence to medications and care plans; improved communication with clinicians and care partners; increased trust of clinicians; being reminded of next steps, such as diagnostic and screening tests; and finding and reporting potential errors in the record.

Importantly, those who do not usually speak English at home or are less educated, nonwhite, older, or Hispanic are most likely to report benefits from note reading.

As patients increasingly read their visit notes through online portals, reports suggest that patient access to notes may improve adherence to medications. A recent study of three diverse health systems that have been sharing notes for seven years shows these results have remained constant over time, even as all three organizations have expanded note sharing beyond primary care to all outpatient settings.

Once introduced to the concept of OpenNotes, more than 90% of patients want easy access to their notes to continue, regardless of whether or not they choose to read an individual note.

What Is the Cost of Implementing OpenNotes?
The majority of EHR vendors, including Allscripts, Cerner, Epic, and Meditech, can enable the sharing of clinical notes to their patient portals with no additional costs.

Technology aside, OpenNotes requires human resources from internal IT staff. OpenNotes implementation is often seen as part of an existing organizational work plan for EHR updates, patient portal recruitment, and/or patient engagement initiatives.

For a detailed look at the implementation process, check out a summary of the 2016 University of Washington OpenNotes rollout, which is available as an open access article through AHIMA’s HIM Body of Knowledge.

How Does OpenNotes Impact Workflow?
In advance of OpenNotes, clinical staff often report anxiety about perceived changes to workflow and workload. However, this anxiety appears to be misplaced. None of the 200 OpenNotes implementers have reported a significant increase in visit time with patients or in e-mail traffic. In fact, some organizations have reported a decrease in e-mail, as patients are able to resolve confusion or forgetfulness by reading their notes.

The one workflow issue that requires short-term changes involves documentation. According to “Your Patient Is Now Reading Your Note: Opportunities, Problems, and Prospects,” published in The American Journal of Medicine, 15% to 20% of clinicians will begin making modest changes in their approach to medical records. While these changes are typically small, some clinicians do report spending more time in documentation after implementing note sharing.

To help patients better understand their notes, documentation best practices are emerging, including the following:

• Avoid abbreviations. For example, “SOB” means something entirely different to patients.

• Avoid pejoratives such as “noncompliant” and “unreliable.” These observations are better off factually documented rather than used to describe a patient.

• Avoid the copying and pasting of information within the chart. Patients and other clinicians might be confused by copy and paste.

• Use plain language.

• Sign notes in a timely manner.

Overall, most organizations perceive these changes, which are quickly integrated into workflow and are usually not an issue after four to six weeks, to be positive.

Will OpenNotes Increase Workload?
Should organizations expect an increase in change requests or amendments to medical records after implementing OpenNotes? The evidence thus far suggests that requests for changes to the medical record via traditional channels (eg, through the medical secretary’s office) will not increase following the implementation of OpenNotes.

If the organization is successful in registering patients for the portal and educating them on its features, patient requests for copies of their medical records may decrease after implementation. It’s been documented that organizations that partner with internal marketing and communications departments to promote OpenNotes have seen a decrease in formal record requests. However, without active communication efforts about the patient portal and OpenNotes functionality, requests for medical record copies will remain unchanged.

An area to be aware of regarding changes is related to errors in the medical record. When patients have access to and read their clinical notes, they can find and report mistakes. The most common errors found by patients are related to inaccurate medications, medical history, and diagnostic issues. Systems can be put into place so that these errors can be acknowledged and addressed; a referral to an HIM committee is rarely needed.

What Are the Coding Concerns Related to OpenNotes?
EHRs serve two purposes: clinical documentation and medical billing. When patients have access to their notes, they occasionally report reading about documented activities that they do not recall being performed, which can lead to accusations of upcoding.

Some clinicians report that the terms they use, such as “noncompliant,” lead to higher reimbursement. Others may use templates for clinical documentation but forget to uncheck/remove services they have not performed. Patients reading these notes may request alterations that could affect reimbursement due to coding changes.

Does OpenNotes Lead to Burnout?
Clinician burnout is an important concern and must be taken seriously. The causes for physician burnout are myriad, including stressful and inefficient work environments, increasing documentation burdens, and odoriferous policies, all of which lead to a sense of powerlessness.

While some experts cite EHR platforms as being major contributors to burnout, others suggest it is the increasing documentation requirements that are to blame, pointing out that physicians using the same EHRs in other countries don’t experience the same affliction. Fortunately, there is no evidence that OpenNotes leads to burnout.

In 1996, HIPAA gave patients access to virtually all the information in their medical records. In the years since, the widespread adoption of EHRs and patient portals has made it technically easy for clinicians and health care organizations to offer patients digital access to their medical records. Now, more than 40 million Americans have the ability to look up their notes.

The 21st Century Cures Act and the recent draft regulations focused on interoperability indicate that note sharing may become far more widespread in the coming years. With proper planning, health care organizations and their HIM departments can offer their patients access to clinical notes and encourage them to use the information to understand their conditions and feel more in control of and engaged in their care.

Learn more about OpenNotes at opennotes.org.

— Catherine M. DesRoches, DrPH, is an associate professor of medicine at Harvard Medical School and the executive director of OpenNotes. She is a distinguished researcher with expertise in emerging trends in health care delivery.

— Liz Salmi, the senior strategist of research dissemination for OpenNotes, helps hospitals and health systems understand the changing nature of patient-clinician communication in the age of connectivity, and interpret and implement research emerging from the OpenNotes movement.