Open Access to Physicians' Notes May Improve Patient Outcomes

According to the final results of a study in the Oct. 2 Annals of Internal Medicine, patients given access to their primary care physician's notes were more engaged in care and saw better outcomes. Additionally, physicians saw little increase in their workload.

The yearlong "quasi-experimental" OpenNotes trial looked at portal use and electronic messaging by more than 13,000 primary care patients who were provided digital links to their doctors' notes at Beth Israel Deaconess Medical Center in Boston, Harborview Medical Center in Seattle, and the Geisinger Health System in central and northeastern Pennsylvania. Patients also took surveys that focused on their perceptions of behaviors, benefits and negative consequences.

According to the authors, study participants frequently accessed notes on their visits, a majority reported clinically relevant benefits and minimal concerns, and most patients indicated they wanted to continue the practice.

"In response to a relatively simple intervention, the patients in this large-scale trial reported striking benefits and presented a clear mandate to continue open notes," the authors wrote. "The doctors encountered few problems, and … since reviewing their individual results as documented in this report, the three participating institutions have each decided to broaden patient access to their clinicians' notes. Despite important limitations … our findings suggest that expanding such transparency is the right thing to do."

Before the project was implemented, many physicians expressed trepidation about opening their notes up to patients. They worried that patients would be confused, worried or offended by what they read; the opposite proved true. According to the study, a "vast majority" of participants reported an increased sense of control, greater understanding of medical issues, improved recall of their plans for care and better preparation for future visits.

"We suspect that fear or uncertainty of what is in the doctor's 'black box' may engender far more anxiety than what is actually written, and patients who are especially likely to react negatively to notes may self-select not to read them," the authors wrote. "Nevertheless, we anticipate that some may be disturbed in the short term by reading their notes, and doctors will need to work with patients to prevent such harms, ideally by talking frankly with them or agreeing proactively that some things are, at times, best left unread. An option to block selected notes from a patient's view may also be helpful as both clinicians and patients tailor care in the future."

Primary care physicians in the study also saw little impact to their work lives. Although a sizable minority changed how they addressed substance abuse, mental health issues, cancer and obesity, many of the comments researchers received suggested that doctors were surprised at the minimal effect opening their notes had on their work level.

"Several wondered whether the intervention had been implemented," the authors wrote. "One comment may best summarize their collective experience: 'My fears: Longer notes, more questions and messages from patients. In reality, it was not a big deal.'"

The study also indicated that "a remarkable number" of participants said open access increased their likelihood to take medications as prescribed.

"We were excited to see that more than half of patients who received medications reported improved adherence, consistent with findings about general adherence from another open-records study" the authors wrote. "Although self-reports fall short of objective data, open notes may prove to be a simple intervention that has an important effect on medication adherence."