Flip No. 17

Share the electronic health record between a patient and clinician

Improve the experience before, during, and after an appointment through OpenNotes.

By Flip the Clinic

OpenNotes began as a simple but radical idea. Patients should be able to review what’s written in their health record.

When the idea was first tested in 2010, medical record transparency was far from standard.

There were long-held concerns about privacy, patient comprehension, and just how much extra time doctors would have to spend explaining the notes to patients. The year-long trial to open up doctor’s notes took place at three sites, led by the Beth Israel Deaconess Medical Center in Boston, with funding from the Robert Wood Johnson Foundation. Over 100 primary care doctors volunteered to invite their patients to view medical notes online.

The results of the trial were overwhelmingly positive. A whopping 92 percent of patients followed through with the invitation to view their most recent health notes securely online. More than 60 percent of patients reported that they were taking their medications better because of OpenNotes, and more than 77 percent said that the program helped them feel like they had more control over their health care.

The trial also found that physicians weren’t overburdened by the change. Fewer than eight percent of doctors spent more time addressing patient concerns outside of visits than they had before. Fewer than 20 percent said that writing notes to be viewed by patients took longer than writing notes before.

Since the trial results were published, the OpenNotes initiative has grown into a movement. Today there are nearly two million Americans with access to notes in their medical record. To better support the initiative, OpenNotes released a free online toolkit in 2014 to guide health care centers through the process of opening up their notes to patients.

Here’s what OpenNotes learned from the rollout at Beth Israel Deaconess Medical Center. (You can learn more about it here.)

1. Engaging leadership from the start makes a difference; having the support of the CEO,
the Chiefs of Medicine and Surgery, and executive-level sponsorship were critical.
2. Don’t underestimate the importance of institutional culture. Clinicians need to be heard
and their concerns respected; meet regularly with clinicians, be accessible to them when
they have questions, and incorporate their ideas on open notes implementation.
3. Developing a communication strategy early helps clinicians prepare for what’s coming.
4. Rolling OpenNotes out in stages allows room to make improvements or fix technical
glitches that could turn off skeptical clinicians at the outset.
5. Clinicians respond well to the OpenNotes study results.

Case Study

During the one year testing period, very few patients (1-8%) reported being confused, worried, or offended by what they read in their notes. 77-85% reported better understanding of their health and medical conditions. 77-87% felt more in control of their care. 70-72% said they took better care of themselves. 60-78% reported doing better with taking their medications. 99% of patients wanted OpenNotes to continue. 85-89% of patients said availability of OpenNotes would influence their future choices of doctors and health plans. An analysis of email traffic before and during the trial showed that overall, doctors did not receive more messages from patients. 17-26% of doctors preferred not to continue, but when offered the chance to stop, none did. Many doctors described strengthened relationships with their patients. (Find the complete results here.)


  • Susan Miller

    This turns out to be much less of a big deal than it sounded like at first. My academic institution did this about 18 months ago after reading about the Open notes project. There was not a lot of push back and leadership just went ahead and implemented. As a primary care physician, I had always told patients the chart was theirs and had printed or shared notes when people asked. BUT they rarely asked. Now I think a lot of them do NOT know they can read all the notes on the portal. After a year I had a few comments from patients but never any trouble. I think it increases engagement and encourage it. I found I really did not change what I was saying in notes knowing the patient would read it though I thought initially this would happen.