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Open Notes: Electronic Medical Record Innovations

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By Lisa Wilson | Image by Pandpstock001/Shutterstock.com |

“Open Notes” is a new initiative in health care.  This progressive new idea moves for greater transparency and access in medical care. The method being suggested to accomplish this is “Open Notes.”  Open Notes are electronic patient care notes written in a format that allows both patients and doctors to have access to this portion of the medical record.

What does this mean to you?  It means that you would have immediate access to the healthcare notes taken by your provider, in electronic format.  You are able to read the notes taken by your doctor about your visit and current health concern. You can read the list of prescribed medications and even the reasons that you are being prescribed the drug.

One complaint many MD’s have is that patients forget what they are told in the office as soon as they leave.  This results in many people being un informed about their own healthcare. “It is generally understood that patients forget 80-90% of what they are told at the doctor’s office.” (http://www.forbes.com/sites/davechase/2012/10/14/doctors-success-hinges-on-transactor-to-teacher-transition/#6b596dfd566b)  In some cases this is dangerous. Patient safety is greatly improved when patients have adequate access to their medical record and information.  A person can then look back at the name of a condition they have been diagnosed with or reference prescribed medications. Some healthcare facilities do provide patient care portals that list prescribed medications and basic links to healthcare information.  The new addition of being able to read the doctors notes will be a great enhancement

The idea behind this is to give patients access to the information that their healthcare provider finds relevant beyond a basic list.  It is also intended to increase transparency and honesty in patient care. If healthcare provider is aware that his or her notes will be reviewed by the patient or their authorized designees this may provide further incentive for thorough and appropriate treatment. This system may also appeal to some physicians because it makes their jobs easier. Improved communication is a benefit for patient and doctor alike. Some patients may be less inclined to use Open Notes because of lack of familiarity with current internet technology.  Simple instructions may be given as well as basic classes teaching patients how to access this information.  Patient portals located onsite at healthcare facilities will also increase patient access to this type of information.

Potential funding sources also look promising for this project.  “Initially supported primarily by the Robert Wood Johnson Foundation, OpenNotes is today funded by generous grants from the Robert Wood Johnson Foundation, the Gordon and Betty Moore Foundation, the Peterson Center on Healthcare and the Cambia Health Foundation, in addition to project-specific grants from CRICO and The Commonwealth Fund of New York.”  ( http://www.opennotes.org/about-opennotes/ ) According to studies done by proponents of this process nearly all participants elected to read their healthcare notes taken by physicians.  For that matter, the physicians did not find this process caused any extra time working on charting or note taking.

 

References:

  1. http://www.opennotes.org/what-is-opennotes-2/why-open-visit-notes/
  1. http://www.forbes.com/sites/davechase/2012/10/14/doctors-success-hinges-on-transactor-to-teacher-transition/#6b596dfd566b
  1. http://www.rwjf.org/en/how-we-work/grants/grantees/OpenNotes.html

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