The STEPS Forward module offers six steps to successfully adopt OpenNotes within the practice.
Educate your practice about clinical note transparency and OpenNotes. Describing and sharing research that showcases the benefits of providing access to clinician notes for both patients and physicians is important. More specifically, physicians can share that the online availability of notes can help patients feel more in control of their health care, have a better understanding of their medical conditions and better adhere to their medications. And, when physicians share their notes, they see significant improvements in patient satisfaction, safety, communication and education. This improves the patient-physician relationship.
Plan what OpenNotes will look like in your practice. Once the benefits have been shared, it is important to take into account policy considerations such as:
- Which physicians or departments will share notes.
- How to introduce patients to OpenNotes.
- How proxies will access patient notes.
- How patient requests to change notes will be handled.
These are all issues that will need to be addressed prior to sharing information with patients. For practices with an electronic health record (EHR) system, it is also vital to work with the vendor to ensure proper implementation.
Prepare your practice and patients. It is normal for physicians and their teams, as well as patients, to show resistance in the beginning phases of any change. By preparing for this potential pushback, practices can discuss the importance of transparency and answer any questions about OpenNotes while educating team members and patients. There is also a “STEPS in practice” section of the module that shares how other practices and physicians are using OpenNotes. The more prepared physicians and their teams are, the easier the transition will be.
Adapt documentation style as needed. Access to notes doesn’t mean the physician or their team needs to change their writing style—most don’t need to make any changes. Keep in mind that it is important to maintain mindfulness when communicating with patients, but also with medical assistants, nurses and others contributing to notes documentation. It is important to:
- Speak or write only about things discussed during the visit.
- Skip commentary that might appear as judgmental.
- Remain positive and supportive.
- Avoid using medical jargon, acronyms or abbreviations.
Learn to handle challenging topics in an OpenNotes environment. Physicians might often worry about how to document challenging topics such as obesity, physical abuse and mental health, among others. These sensitive issues require special attention, but physicians still remain unsure of how to document this information. While it is natural to want to avoid or limit the information provided in documentation, it will benefit patients to hear direct dialogue from physicians at their in-person visit and through documentation later.
Collect patient and physician feedback about OpenNotes to refine your approach. To understand the impact of OpenNotes it is important to receive feedback from patients, physicians and other team members. By establishing a baseline, midpoint and endpoint for the initiative, practices can collect necessary information to better understand the impact of offering notes for patients. Whether it is done in passing or through tracking the volume of emails and patient calls, physicians and practices should be gathering feedback to improve their use of OpenNotes.
The module may be completed for continuing medical education credit. The AMA’s STEPS Forward collection features six new practice-improvement modules bringing the total to 49. Several come thanks to a grant from, and in collaboration with, the Transforming Clinical Practices Initiative.