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Figure.  Survey Results
Survey Results

Clinicians were asked whether they agreed with the statement “Making visit notes available to patients is a good idea.” They were also asked, “Would you find it helpful to have an indictor in the medical record showing whether a patient has read a note?” APN indicates advanced practice nurse; PA, physician assistant; and PCP, primary care physician.

Table 1.  Respondent Characteristics
Respondent Characteristics
Table 2.  Perceptions of and Experiences With Open Notes of Clinicians Aware That Patients Were Reading Their Notes
Perceptions of and Experiences With Open Notes of Clinicians Aware That Patients Were Reading Their Notes
Table 3.  Physicians’ Perceptions of and Experiences With Open Notes
Physicians’ Perceptions of and Experiences With Open Notes
Table 4.  Changes in Note Writing Among Physicians
Changes in Note Writing Among Physicians
1.
Office of the National Coordinator for Health Information Technology. 21st Century Cures Act: Interoperability, Information Blocking, and the ONC Health IT Certification Program. Published 2020. Accessed March 9, 2020. https://www.healthit.gov/cerus/sites/cerus/files/2020-03/ONC_Cures_Act_Final_Rule_03092020.pdf
2.
Office of the National Coordinator for Health Information Technology. United States Core Data for Interoperability. Published 2020. Accessed March 9, 2020. https://www.healthit.gov/isa/united-states-core-data-interoperability-uscdi
3.
Centers for Medicare and Medicaid Services. CMS advances interoperability and patient access to health data through new proposals. Published February 8, 2019. Accessed September 9, 2019. https://www.cms.gov/newsroom/fact-sheets/cms-advances-interoperability-patient-access-health-data-through-new-proposals
4.
Delbanco  T, Walker  J, Bell  SK,  et al.  Inviting patients to read their doctors’ notes: a quasi-experimental study and a look ahead.  Ann Intern Med. 2012;157(7):461-470. doi:10.7326/0003-4819-157-7-201210020-00002PubMedGoogle ScholarCrossref
5.
Dobscha  SK, Denneson  LM, Jacobson  LE, Williams  HB, Cromer  R, Woods  S.  VA mental health clinician experiences and attitudes toward OpenNotes.  Gen Hosp Psychiatry. 2016;38:89-93. doi:10.1016/j.genhosppsych.2015.08.001PubMedGoogle ScholarCrossref
6.
Woods  SS, Schwartz  E, Tuepker  A,  et al.  Patient experiences with full electronic access to health records and clinical notes through the My HealtheVet Personal Health Record Pilot: qualitative study.  J Med Internet Res. 2013;15(3):e65. doi:10.2196/jmir.2356PubMedGoogle Scholar
7.
Walker  J, Leveille  S, Bell  S,  et al.  OpenNotes after 7 years: patient experiences with ongoing access to their clinicians’ outpatient visit notes.  J Med Internet Res. 2019;21(5):e13876. doi:10.2196/13876PubMedGoogle Scholar
8.
Mishra  VK, Hoyt  RE, Wolver  SE, Yoshihashi  A, Banas  C.  Qualitative and quantitative analysis of patients’ perceptions of the patient portal experience with OpenNotes.  Appl Clin Inform. 2019;10(1):10-18. doi:10.1055/s-0038-1676588PubMedGoogle ScholarCrossref
9.
Huang  JS, Yueh  R, Ma  S, Cruz  R, Bauman  L, Choi  LJ.  Adolescents’ and young adults’ satisfaction with and understanding of medical notes from a pediatric gastroenterology practice: a cross-sectional cohort study.  J Pediatr. 2019;215:264-266. doi:10.1016/j.jpeds.2019.06.052PubMedGoogle ScholarCrossref
10.
Giannouli  V.  Giving doctors’ daily progress notes to hospitalized patients and families: a reflection.  Am J Med Qual. 2017;32(4):459. doi:10.1177/1062860617699698PubMedGoogle ScholarCrossref
11.
OpenNotes. OpenNotes homepage. Accessed November 26, 2019. https://www.opennotes.org/
12.
American Association for Public Opinion Research. Standard definitions: final dispositions of case codes and outcome rates for surveys. 9th Edition. Published 2016. Accessed January 14, 2020. https://www.aapor.org/AAPOR_Main/media/publications/Standard-Definitions20169theditionfinal.pdf
13.
Klein  JW, Jackson  SL, Bell  SK,  et al.  Your patient is now reading your note: opportunities, problems, and prospects.  Am J Med. 2016;129(10):1018-1021. doi:10.1016/j.amjmed.2016.05.015PubMedGoogle ScholarCrossref
14.
Rahimian  M, Warner  JL, Jain  SK, Davis  RB, Zerillo  JA, Joyce  RM.  Significant and distinctive n-grams in oncology notes: a text-mining method to analyze the effect of OpenNotes on clinical documentation.  JCO Clin Cancer Inform. 2019;3:1-9. doi:10.1200/CCI.19.00012PubMedGoogle ScholarCrossref
15.
Chung  GH, Choi  JN, Du  J.  Tired of innovations? learned helplessness and fatigue in the context of continuous streams of innovation implementation.  J Organ Behav. 2017;38(7):1130-1148. doi:10.1002/job.2191Google ScholarCrossref
16.
Howick  J, Steinkopf  L, Ulyte  A, Roberts  N, Meissner  K.  How empathic is your healthcare practitioner? a systematic review and meta-analysis of patient surveys.  BMC Med Educ. 2017;17(1):136. doi:10.1186/s12909-017-0967-3PubMedGoogle ScholarCrossref
17.
Roter  DL, Hall  JA.  Physician gender and patient-centered communication: a critical review of empirical research.  Annu Rev Public Health. 2004;25(1):497-519. doi:10.1146/annurev.publhealth.25.101802.123134PubMedGoogle ScholarCrossref
18.
Puffer  JC, Knight  HC, O’Neill  TR,  et al.  Prevalence of burnout in board certified family physicians.  J Am Board Fam Med. 2017;30(2):125-126. doi:10.3122/jabfm.2017.02.160295PubMedGoogle ScholarCrossref
19.
Bell  SK, Mejilla  R, Anselmo  M,  et al.  When doctors share visit notes with patients: a study of patient and doctor perceptions of documentation errors, safety opportunities and the patient-doctor relationship.  BMJ Qual Saf. 2017;26(4):262-270. doi:10.1136/bmjqs-2015-004697PubMedGoogle ScholarCrossref
20.
DesRoches  CM, Bell  SK, Dong  Z,  et al.  Patients managing medications and reading their visit notes: a survey of OpenNotes participants.  Ann Intern Med. 2019;171(1):69-71. doi:10.7326/M18-3197PubMedGoogle ScholarCrossref
21.
Bell  SK, Folcarelli  P, Fossa  A,  et al.  Tackling ambulatory safety risks through patient engagement: what 10,000 patients and families say about safety-related knowledge, behaviors, and attitudes after reading visit notes.  J Patient Saf. 2018;00(00):1-9. doi:10.1097/PTS.0000000000000494PubMedGoogle ScholarCrossref
23.
Wiebe  ER, Kaczorowski  J, MacKay  J.  Why are response rates in clinician surveys declining?  Can Fam Physician. 2012;58(4):e225-e228.PubMedGoogle Scholar
24.
Taylor  T, Scott  A.  Do physicians prefer to complete online or mail surveys? findings from a national longitudinal survey  [published online November 1, 2018].  Eval Health Prof. doi:10.1177/0163278718807744PubMedGoogle Scholar
25.
Sebo  P, Maisonneuve  H, Cerutti  B, Fournier  JP, Senn  N, Haller  DM.  Rates, delays, and completeness of general practitioners’ responses to a postal versus web-based survey: a randomized trial.  J Med Internet Res. 2017;19(3):e83. doi:10.2196/jmir.6308PubMedGoogle Scholar
26.
Cook  C, Heath  F, Thompson  RL.  A meta-analysis of response rates in web- or internet-based surveys.  Educ Psychol Meas. 2000;60(6):821-836. doi:10.1177/00131640021970934Google ScholarCrossref
27.
Blackstock  OJ, Moore  BA, Berkenblit  GV,  et al.  A cross-sectional online survey of HIV pre-exposure prophylaxis adoption among primary care physicians.  J Gen Intern Med. 2017;32(1):62-70. doi:10.1007/s11606-016-3903-zPubMedGoogle ScholarCrossref
28.
Keeter  S, Kennedy  C, Dimock  M, Best  J, Craighill  P.  Gauging the impact of growing nonresponse on estimates from a national RDD telephone survey.  Public Opin Q. 2006;70(5):759-779. doi:10.1093/poq/nfl035Google ScholarCrossref
29.
Curtin  R, Presser  S, Singer  E.  The effects of response rate changes on the index of consumer sentiment.  Public Opin Q. 2000;64(4):413-428. doi:10.1086/318638PubMedGoogle ScholarCrossref
30.
Kellerman  SE, Herold  J.  Physician response to surveys: a review of the literature.  Am J Prev Med. 2001;20(1):61-67. doi:10.1016/S0749-3797(00)00258-0PubMedGoogle ScholarCrossref
31.
U.S. Department of Health and Human Services. Summary of the HIPAA privacy rule. Published 2019. Accessed November 13, 2019. https://www.hhs.gov/hipaa/for-professionals/privacy/laws-regulations/index.html
32.
Patel  V, Johnson  C; The Office of the National Coordinator for Health Information Technology. Individuals’ use of online medical records and technology for health needs. Published 2018. Accessed July 29, 2019. https://www.healthit.gov/sites/default/files/page/2018-03/HINTS-2017-Consumer-Data-Brief-3.21.18.pdf
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    1 Comment for this article
    EXPAND ALL
    Patient Involvement And Transparency Drives Patient Advocacy And Trust
    Peter Shah, BSc MA FRCOphth FRCP Edin | University Hospitals Birmingham NHS Foundation Trust
    Following on from the important findings of Catherine DesRoches et al, I would like to put forward four simple premises:

    [1] Patients are the clinicians best advocates.
    [2] Patient involvement in their care drives patient advocacy.
    [3] Giving patients access to their records is a key threshold in patient involvement and this transparency enables them to see how hard clinicians are working on their behalf.
    [4] This transparency helps to build the foundation of trust with clinicians.

    I work in a supra-regional tertiary practice and deal with many patients with complex previous medical histories. My first step is
    to pull together all previous information and create an itemised chronological medical summary of the key elements of the patients journey to date. This summary is the first element within all patient letters to other clinicians involved in the patient's care. A summary of current drug therapy and then the current clinical findings / investigations and management plan follow. The letter is copied to the patient.

    I have been stunned at the number of patients who have specifically made the effort to thank me for the letter - they appreciate the time and effort I have made for them. Setting the right initial tone of trust and advocacy is essential in the subsequent patient journey - in helping them to heal...
    CONFLICT OF INTEREST: None Reported
    READ MORE
    Original Investigation
    Health Policy
    March 27, 2020

    The Views and Experiences of Clinicians Sharing Medical Record Notes With Patients

    Author Affiliations
    • 1Harvard Medical School, Boston, Massachusetts
    • 2Beth Israel Deaconess Medical Center, Boston, Massachusetts
    • 3College of Nursing and Health Sciences, University of Massachusetts, Boston
    • 4David Geffen School of Medicine, University of California, Los Angeles
    • 5University of California, Los Angeles Fielding School of Public Health
    • 6University of Washington, UW Medicine, Seattle
    • 7Steele Institute for Health Innovation, Geisinger, Danville, Pennsylvania
    JAMA Netw Open. 2020;3(3):e201753. doi:10.1001/jamanetworkopen.2020.1753
    Key Points español 中文 (chinese)

    Question  How do clinicians with experience in sharing notes with patients view this new practice?

    Findings  In this web-based survey study of 1628 clinicians, most viewed note sharing positively (74% agreed that it is a good idea and 74% viewed shared notes as useful for engaging patients in their care), and 37% of physicians surveyed reported spending more time in documentation. Physicians with more years in practice and fewer hours spent in patient care had more positive opinions overall.

    Meaning  Findings from this large survey across specialties in institutions with a history of note sharing suggest few drawbacks for clinicians as they prepare for this rapidly evolving change in practice.

    Abstract

    Importance  The 21st Century Cures Act of 2016 requires that patients be given electronic access to all the information in their electronic medical records. The regulations for implementation of this law give patients far easier access to information about their care, including the notes their clinicians write.

    Objective  To assess clinicians’ views and experiences with sharing clinical notes (open notes) with patients.

    Design, Setting, and Participants  Web-based survey study of physicians, advanced practice nurses, registered nurses, physician assistants, and therapists at 3 health systems in Boston, Massachusetts; Seattle, Washington; and rural Pennsylvania where notes have been shared across all outpatient specialties for at least 4 years. Participants were clinicians in hospital-based offices and community practices who had written at least 1 note opened by a patient in the year prior to the survey, which was administered from May 21, 2018, to August 31, 2018.

    Main Outcomes and Measures  Clinicians’ experiences with and perceptions of sharing clinical notes with patients.

    Results  Invitations were sent to 6064 clinicians; 1628 (27%) responded. Respondents were more likely than nonrespondents to be female (65% vs 55%) and to be younger (mean [SD] age, 42.1 [12.6] vs 44.9 [12.7] years). The majority of respondents were physicians (951 [58%]), female (1023 [65%]), licensed to practice in 2000 or later (940 [61%]), and spent fewer than 40 hours per week in direct patient care (1083 [71%]). Most viewed open notes positively, agreeing they are a good idea (1182 participants [74%]); of 1314 clinicians who were aware that patients were reading their notes, 965 (74%) agreed that open notes were useful for engaging patients. In all, 798 clinicians (61%) would recommend the practice to colleagues. A total of 292 physicians (37%) reported spending more time on documentation, and many reported specific changes in the way they write their notes, the most frequent of which related to use of language that could be perceived as critical of the patient (422 respondents [58%]). Most physicians (1234 [78%]) favored being able to determine readily that their notes had been read by their patients.

    Conclusions and Relevance  In this survey of clinicians in a wide range of specialties who had several years of experience offering their patients ready access to their notes, more than two-thirds supported this new practice. Even among subgroups of clinicians who were less enthusiastic, most endorsed the idea of sharing notes and believed the practice could be helpful for engaging patients more actively in their care.

    Introduction

    A decade ago, the notion of offering patients ready access to their clinical notes (open notes) was a fringe idea. Today, the debate over transparency in health care has taken center stage and has become a pressing legislative and regulatory issue.1,2 The 21st Century Cures Act of 2016 requires that patients be given electronic access to the information in their medical records, and recent regulations from the Office of the National Coordinator for Health Information Technology substantially expand the type of information that must be both easily accessible to patients and readily exchanged among clinicians in electronic form. Coupled with the new price transparency required by the Centers for Medicare and Medicaid Services,3 patients will soon have easier access to far more detailed information about their care.

    In 2012, findings were published4 from a pilot project examining the effects of sharing clinical notes with patients receiving primary care in 3 health care systems. The findings suggested patients derived potentially important benefits from reading their notes, and few clinicians reported negative effects on workflow or documentation practices. Thereafter, the 3 systems spread the availability of these notes through virtually all their ambulatory care practices, and recent surveys of more than 20 000 patients at the 3 sites, along with other research conducted in private health care organizations and the Veterans Administration, have shown similar results.5-10 The practice of note sharing has spread, and at the beginning of 2020, more than 44 million patients at more than 200 US health care organizations have access to their notes through patient portals.11

    The early reports from physicians on the effects of sharing clinical notes with patients via secure online portals were based on a limited sample of volunteering primary care physicians (PCPs) who were given the opportunity to exclude some of their patients.4 Whether these positive results would hold across clinicians of different types who share notes with virtually all their patients is unknown. Negative impacts might emerge when a wide variety of patients are accessing and reading their notes across specialties over time.

    In the pilot organizations, virtually all the clinicians, including many in mental illness specialties, have now been sharing their office notes for 4 years or more. Based on our experiences working with health care organizations to implement open notes, we hypothesized that both PCPs and specialists would hold positive views about sharing notes. We expected that PCPs, younger physicians, and female physicians would be more positive overall, and that some would report changes in their documentation practices. To examine these issues, we surveyed a broad array of clinicians in all specialties practicing at our original pilot sites, including physicians, advanced practice nurses (APNs), physician assistants (PAs), registered nurses, therapists, and other clinicians. We examined their experiences with and perceptions about sharing notes with patients and their reports of the effects of this transparency on their documentation practices.

    Methods
    Setting

    We conducted a web-based survey of clinicians in hospital-based offices and community practices at 3 health systems: Beth Israel Deaconess Medical Center (BIDMC) (Boston, Massachusetts), Geisinger (Pennsylvania), and University of Washington Medicine (UW) (Seattle). At each site, notes are shared by almost all outpatient clinicians, including PCPs, specialist physicians, APNs, PAs, therapists, and others. The institutional review boards at BIDMC, Geisinger, and UW approved the survey and study protocol at their respective sites. Each waived the requirement for informed consent, as answering the survey was deemed to be implied consent. Reporting of this study follows the American Association for Public Opinion Research (AAPOR) reporting guideline.

    Participants

    The survey included clinicians in multispecialty outpatient care practices: at the hospital and 6 affiliated sites at BIDMC, at 3 hospitals and 9 freestanding clinics at UW, and at 7 hospitals and 53 outlying practices at Geisinger. We contacted all clinicians who had at least 1 visit note opened by a patient in the year prior to the survey.

    Constructing the Questionnaire

    This survey draws heavily on the original pilot questionnaire and includes additional questions regarding clinician characteristics and changes in documentation practices.4 Clinicians who reported they were not aware that patients were reading their notes were asked only if they agreed or disagreed with the statement “making notes available to patients online is a good idea,” whether they would like an indicator in the electronic health record showing a note had been read, and demographic questions. The questionnaire is available in the eAppendix in the Supplement.

    Conducting the Survey

    We sent invitations to clinicians’ institutional email addresses between May and August 2018 using REDCap (Vanderbilt), an online, public use secure data management package. Each invitation contained the clinician’s unique study identification number embedded in a link to the survey. We sent clinicians up to 3 reminders 1 week apart if they had not completed the survey. Each site offered clinicians a modest incentive by lottery, available to those who submitted completed surveys. Participating clinicians at the BIDMC and UW could win 1 of 5 $500 prizes (paid as a check at BIDMC and gift card at UW), and at Geisinger they were eligible to win 1 of 25 $100 checks. Clinicians completed the survey from May 21, 2018, to August 31, 2018.

    Statistical Analysis

    We categorized clinicians who completed the survey as PCPs, specialist physicians, APNs or PAs, or other clinicians, based either on survey responses or administrative data when the response about professional role was missing. Respondent sex was taken from administrative data. All items reported in this analysis had less than 4% missing responses. Using descriptive statistics, we first compared respondents with nonrespondents using variables from the sampling file (sex and age). Responses using a 4-point agree-disagree scale were collapsed into 2 categories: agree or somewhat agree and disagree or somewhat disagree. We dichotomized survey items addressing frequency: daily, weekly, or monthly and less than monthly or never. Because documentation burden for physicians is such a pressing and important topic, we restricted our analysis of how documentation practices may change owing to open notes to physicians. We used the χ2 of independence test to test for differences among clinician groups. The threshold for statistical significance was set at 2-sided P < .05. We conducted all the statistical analyses at BIDMC using SAS software version 9.4 (SAS Institute Inc).

    Results
    Participants

    We sent invitations to 6064 clinicians, and 1628 responded (response rate = 27%, using the Response Rate Calculation 2 of the AAPOR guideline) (eFigure in the Supplement).12 Respondents were more likely than nonrespondents to be female (65% vs 55%) and to be younger (mean [SD] age, 42.1 [12.6] vs 44.9 [12.7] years) (eTable in the Supplement). The majority of respondents were physicians (951 [58%]), female (1023 [65%]), licensed to practice in 2000 or later (940 [61%]), and spent fewer than 40 hours per week in direct patient care (1083 [71%]) (Table 1).

    Perceptions and Experiences of All Clinicians

    Seventy-four percent of clinicians (1182) agreed that making notes available to patients is a good idea, and 78% (1234) reported they would find it helpful to have an electronic health record indicator showing whether a patient had read a note (Figure). Among the 1314 clinicians (82%) who were aware that patients were reading their notes, 74% (965) agreed that open notes are a useful tool for engaging patients in their care, and 61% (798) would recommend open notes to colleagues at other institutions (Table 2).

    Twenty-five percent of clinicians (330) reported encouraging patients to read their notes, 18% (232) said patients mentioned notes during visits at least monthly, and 14% (187) reported patients contacting the office about their notes outside of visits at least monthly (Table 2). Thirty-six percent of clinicians (463) reported spending more time writing their notes because of open notes, while 63% (808) reported no change or spending less time. Eighteen percent of clinicians (234) felt that because of changes due to open notes, their notes became less valuable to other clinicians. While most clinicians said open notes had no effect on the value of their notes, physicians reported that sharing notes with patients reduced the value of their documentation more often than other clinicians (physicians, 22%; APN or PA, 10%; other, 15%; P < .001).

    Physician Perceptions, Experiences, and Characteristics

    Most physician respondents held positive views about open notes. However, there were significant differences by physician characteristics. Primary care physicians more often stated that they would recommend the practice to colleagues (PCP, 64% vs specialist, 54%; P = .008) (Table 3). Compared with those licensed earlier, fewer physicians licensed to practice since 2000 said that they would recommend open notes to colleagues at other institutions (before 2000, 65% vs 2000 or later, 53%; P = .001). Compared with those who spent less than 40 hours per week on patient care, physicians spending at least 40 hours per week more often agreed that making notes available to patients was a good idea (<40 hours, 74% vs ≥40 hours, 64%; P < .001), that open notes were useful for engaging patients in their care (<40 hours, 72% vs ≥40 hours, 63%; P = .01), and that they would recommend open notes to colleagues in other institutions (<40 hours, 61% vs ≥40 hours, 50%; P = .004).

    A total of 292 physicians (37%) reported spending more time on documentation. More female physicians reported increased time spent on documentation compared with their male counterparts (female, 44% vs male, 31%; P < .001), as did those licensed to practice after 2000 compared with those licensed prior to 2000 (2000 or later, 41% vs before 2000, 30%; P = .009). More than three-quarters of both PCPs (77%) and specialists (74%) reported that open notes had no effect on the value of their notes for other clinicians. We found no significant differences in beliefs about the effects of open notes on the value of documentation by sex, hours worked, or year of license.

    Open Notes and Documentation of Physician Encounters

    Physicians reported that open notes led them to make several changes in the way they document visits (Table 4). In general, primary care physicians and female physicians more often reported making changes, as did those licensed to practice medicine after 2000 compared with those licensed to practice before 2000. The change cited most frequently related to the use of language that could be perceived as critical of the patient (422 physicians [58%]).

    Discussion

    In our survey of clinicians in a wide range of specialties who had several years of experience offering their patients ready access to their notes, more than two-thirds supported this new practice. Some subgroups of clinicians were less enthusiastic than others, but even among these, most endorsed the idea of sharing notes and believed the practice could be helpful for engaging patients more actively in their care. While slightly more than one-third of clinicians reported spending more time in documentation, most found the practice did not affect their workflow and would recommend it to colleagues at other institutions. Physicians spending fewer than 40 hours per week in direct patient care were more positive about open notes than were those with more practice hours. Contrary to our expectations, physicians with more years in practice were more positive than were those with fewer years of experience. As the health care system moves toward offering patients ready access to clinical notes, our findings overall suggest few drawbacks for clinicians and health care organizations worried about being overwhelmed by this move toward transparent communication.

    The results of our survey indicated that older physicians were more comfortable with open notes. We can only speculate on the reasons for this. More years in practice bring more established relationships, and perhaps greater appreciation for the importance of communication, along with greater confidence in listening and note-writing skills. Conversely, young physicians may feel more stress, competing priorities, or anxiety about building trust with their patients.

    Our findings suggest that clinicians are generally positive about open notes; however, some responses indicate this result should be interpreted with caution and explored further. Approximately one-third of clinicians report that because of open notes they are spending at least some additional time in documentation. Even if the actual increase in time is minimal, such perceptions are important. While we do not have independent confirmation of actual increased time spent, these reports may signal additional logistical, cognitive, or linguistic effort clinicians perceive when they write shared notes. Many physicians reported modifying the way they document visits, reporting, in particular, changing their use of critical language and sensitive information. Other research suggests that some clinicians may simplify their language, while others make it more complex.13,14 Given the current focus on documentation burden, we need to learn far more about whether and how note sharing is changing documentation practices.

    Physicians with greater patient care responsibilities had less positive perceptions of open notes, but we found no differences in time spent on documentation or how notes were written between these physicians and those seeing patients for fewer than 40 hours per week. One possible explanation is that while note sharing may not be changing workflow substantially, busy clinicians may view it as simply one more thing to think about during the day. Additionally, innovation fatigue may play a role.15 Clinicians, weary from the pace of change in health care, may simply be uninterested in any new initiative.

    More female physicians reported making changes to their notes and spending more time on documentation compared with their male counterparts. Prior research has found that female physicians show more empathy toward patients, ask more questions, and spend more time talking with them than their male counterparts.16,17 Increased time and changes in documentation may reflect the relational nature of the way female physicians practice. Research also suggests that female physicians are at increased risk for burnout. Whether for female or male physicians, it is critical that health care organizations provide adequate support to ensure that note sharing does not increase the challenges of documentation in a way that leads to greater burnout.18

    Reports of more time in documentation should also be assessed in the context of patient reports of the impact of reading their notes. Surveys find that patients overwhelmingly want access to their notes and report benefits from reading them that may have important clinical implications.7 They indicate that reading notes improves their trust, helps them feel more in control of their care, is important in helping them to understand what their clinicians are thinking, and helps them adhere to treatment plans and medications more effectively. Patients also state that the availability of notes will affect their future choice of a health care provider.7,19 Moreover, this improved trust and associated relational benefits may accrue to both patients and clinicians, resulting in stronger relationships.19-21

    Furthermore, more than 3 out of 4 clinicians felt that knowing which of their patients had reviewed their notes would be helpful. To our knowledge, none of the major electronic health record vendors offer such functionality routinely. Indeed, few are able to calculate the percentage of notes patients read. Not knowing whether a patient has read a note may explain why few physicians report discussing them with patients. Feedback loops and measurements that are helpful to both patients and clinicians remain works in progress.

    Limitations

    Our study has a number of limitations. First, we surveyed clinicians in 3 health care organizations that began sharing notes in 2010, limiting the generalizability of our findings. Clinicians in other types of organizations and those without a long history of note sharing may have different opinions and experiences. Second, our survey response rate was modest, and those who responded may have differed from nonresponders in attitudes and experiences. It is well known that survey response rates overall are declining, and surveys of physicians are no exception.19,20 However, our response rate was not markedly different from, and in some cases was better than, other physician surveys conducted online.22-27 Furthermore, a low response rate is not necessarily an indication of response bias,28,29 particularly for physician respondents,30 but we cannot eliminate the possibility that our respondents may differ in important ways from those who did not respond to the survey. They may have been systematically more or less enthusiastic about open notes, thereby creating response bias. However, without more information on the attitudes and experiences of nonrespondents, we can only speculate on the direction this bias might take. Third, as with most survey research, we relied on the accuracy of respondent self-report. In particular, we have not verified respondents’ reports of changes in the amount of time spent or changes to documentation. It is possible that their responses were affected by other unmeasured factors related to their work. In addition, while we drew heavily from a previously developed questionnaire, we did not conduct formal validity and reliability testing for the survey instrument.4

    Conclusions

    In 1996, the Health Insurance Portability and Accountability Act (HIPAA) gave patients access to the information in their medical records.31 In the years since, the widespread adoption of electronic health records and patient portals has made it technically easy for clinicians and health care organizations to offer patients digital access to their medical records. Most people in the US can now use patient portals to make appointments, view test results, request medication refills, and send messages to a clinician, but access to notes has lagged.32 Nevertheless, many individuals now have access to their notes, and the 21st Century Cures Act and regulations will make note sharing more common in the coming years.1,2

    Open notes may help clinicians, patients, and families improve care by moving toward more open communication and partnership. Findings from this large survey across specialties in institutions with a history of note sharing suggest few drawbacks for clinicians as they prepare for this change. As they explore this new practice further, the next challenge comes in providing adequate education and support to patients, families, clinicians, and health systems. If organizations do not prioritize this work of education and culture change, patients may not know that clinicians write notes, many more will not realize that they might benefit from reading them, and we may miss the opportunity to capitalize on the benefits note sharing may bring. Establishing transparency within the fabric of practice is progressing, but considerable work lies ahead before it becomes a new standard of care.

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    Article Information

    Accepted for Publication: January 24, 2020.

    Published: March 27, 2020. doi:10.1001/jamanetworkopen.2020.1753

    Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2020 DesRoches CM et al. JAMA Network Open.

    Corresponding Author: Catherine M. DesRoches, DrPH, Harvard Medical School, Beth Israel Deaconess Medical Center, 133 Brookline Ave, Annex 2nd Flr, Boston, MA 02215 (cdesroch@bidmc.harvard.edu).

    Author Contributions: Dr DesRoches and Ms Walker had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Dr Delbanco and Ms Walker are joint senior authors.

    Concept and design: DesRoches, Leveille, Fernandez, Harcourt, Fitzgerald, Payne, Stametz, Delbanco, Walker.

    Acquisition, analysis, or interpretation of data: DesRoches, Leveille, Bell, Dong, Elmore, Fernandez, Fitzgerald, Payne, Walker.

    Drafting of the manuscript: DesRoches, Elmore, Fitzgerald, Payne, Delbanco.

    Critical revision of the manuscript for important intellectual content: DesRoches, Leveille, Bell, Dong, Elmore, Fernandez, Harcourt, Fitzgerald, Payne, Stametz, Walker.

    Statistical analysis: Leveille, Dong, Fitzgerald, Walker.

    Obtained funding: DesRoches, Elmore, Delbanco, Walker.

    Administrative, technical, or material support: Harcourt, Fitzgerald, Payne, Stametz.

    Supervision: DesRoches, Fitzgerald, Payne.

    Conflict of Interest Disclosures: Dr Bell reported receiving grants from the Agency for Healthcare Research and Quality outside the submitted work. Dr Payne reported receiving grants from the Agency for Healthcare Research and Quality and Brotman Baty Institute outside the submitted work. No other disclosures were reported.

    Funding/Support: This work was supported by the Robert Wood Johnson Foundation, the Cambia Health Foundation, the Gordon and Betty Moore Foundation, and the Petersen Center on Healthcare.

    Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

    References
    1.
    Office of the National Coordinator for Health Information Technology. 21st Century Cures Act: Interoperability, Information Blocking, and the ONC Health IT Certification Program. Published 2020. Accessed March 9, 2020. https://www.healthit.gov/cerus/sites/cerus/files/2020-03/ONC_Cures_Act_Final_Rule_03092020.pdf
    2.
    Office of the National Coordinator for Health Information Technology. United States Core Data for Interoperability. Published 2020. Accessed March 9, 2020. https://www.healthit.gov/isa/united-states-core-data-interoperability-uscdi
    3.
    Centers for Medicare and Medicaid Services. CMS advances interoperability and patient access to health data through new proposals. Published February 8, 2019. Accessed September 9, 2019. https://www.cms.gov/newsroom/fact-sheets/cms-advances-interoperability-patient-access-health-data-through-new-proposals
    4.
    Delbanco  T, Walker  J, Bell  SK,  et al.  Inviting patients to read their doctors’ notes: a quasi-experimental study and a look ahead.  Ann Intern Med. 2012;157(7):461-470. doi:10.7326/0003-4819-157-7-201210020-00002PubMedGoogle ScholarCrossref
    5.
    Dobscha  SK, Denneson  LM, Jacobson  LE, Williams  HB, Cromer  R, Woods  S.  VA mental health clinician experiences and attitudes toward OpenNotes.  Gen Hosp Psychiatry. 2016;38:89-93. doi:10.1016/j.genhosppsych.2015.08.001PubMedGoogle ScholarCrossref
    6.
    Woods  SS, Schwartz  E, Tuepker  A,  et al.  Patient experiences with full electronic access to health records and clinical notes through the My HealtheVet Personal Health Record Pilot: qualitative study.  J Med Internet Res. 2013;15(3):e65. doi:10.2196/jmir.2356PubMedGoogle Scholar
    7.
    Walker  J, Leveille  S, Bell  S,  et al.  OpenNotes after 7 years: patient experiences with ongoing access to their clinicians’ outpatient visit notes.  J Med Internet Res. 2019;21(5):e13876. doi:10.2196/13876PubMedGoogle Scholar
    8.
    Mishra  VK, Hoyt  RE, Wolver  SE, Yoshihashi  A, Banas  C.  Qualitative and quantitative analysis of patients’ perceptions of the patient portal experience with OpenNotes.  Appl Clin Inform. 2019;10(1):10-18. doi:10.1055/s-0038-1676588PubMedGoogle ScholarCrossref
    9.
    Huang  JS, Yueh  R, Ma  S, Cruz  R, Bauman  L, Choi  LJ.  Adolescents’ and young adults’ satisfaction with and understanding of medical notes from a pediatric gastroenterology practice: a cross-sectional cohort study.  J Pediatr. 2019;215:264-266. doi:10.1016/j.jpeds.2019.06.052PubMedGoogle ScholarCrossref
    10.
    Giannouli  V.  Giving doctors’ daily progress notes to hospitalized patients and families: a reflection.  Am J Med Qual. 2017;32(4):459. doi:10.1177/1062860617699698PubMedGoogle ScholarCrossref
    11.
    OpenNotes. OpenNotes homepage. Accessed November 26, 2019. https://www.opennotes.org/
    12.
    American Association for Public Opinion Research. Standard definitions: final dispositions of case codes and outcome rates for surveys. 9th Edition. Published 2016. Accessed January 14, 2020. https://www.aapor.org/AAPOR_Main/media/publications/Standard-Definitions20169theditionfinal.pdf
    13.
    Klein  JW, Jackson  SL, Bell  SK,  et al.  Your patient is now reading your note: opportunities, problems, and prospects.  Am J Med. 2016;129(10):1018-1021. doi:10.1016/j.amjmed.2016.05.015PubMedGoogle ScholarCrossref
    14.
    Rahimian  M, Warner  JL, Jain  SK, Davis  RB, Zerillo  JA, Joyce  RM.  Significant and distinctive n-grams in oncology notes: a text-mining method to analyze the effect of OpenNotes on clinical documentation.  JCO Clin Cancer Inform. 2019;3:1-9. doi:10.1200/CCI.19.00012PubMedGoogle ScholarCrossref
    15.
    Chung  GH, Choi  JN, Du  J.  Tired of innovations? learned helplessness and fatigue in the context of continuous streams of innovation implementation.  J Organ Behav. 2017;38(7):1130-1148. doi:10.1002/job.2191Google ScholarCrossref
    16.
    Howick  J, Steinkopf  L, Ulyte  A, Roberts  N, Meissner  K.  How empathic is your healthcare practitioner? a systematic review and meta-analysis of patient surveys.  BMC Med Educ. 2017;17(1):136. doi:10.1186/s12909-017-0967-3PubMedGoogle ScholarCrossref
    17.
    Roter  DL, Hall  JA.  Physician gender and patient-centered communication: a critical review of empirical research.  Annu Rev Public Health. 2004;25(1):497-519. doi:10.1146/annurev.publhealth.25.101802.123134PubMedGoogle ScholarCrossref
    18.
    Puffer  JC, Knight  HC, O’Neill  TR,  et al.  Prevalence of burnout in board certified family physicians.  J Am Board Fam Med. 2017;30(2):125-126. doi:10.3122/jabfm.2017.02.160295PubMedGoogle ScholarCrossref
    19.
    Bell  SK, Mejilla  R, Anselmo  M,  et al.  When doctors share visit notes with patients: a study of patient and doctor perceptions of documentation errors, safety opportunities and the patient-doctor relationship.  BMJ Qual Saf. 2017;26(4):262-270. doi:10.1136/bmjqs-2015-004697PubMedGoogle ScholarCrossref
    20.
    DesRoches  CM, Bell  SK, Dong  Z,  et al.  Patients managing medications and reading their visit notes: a survey of OpenNotes participants.  Ann Intern Med. 2019;171(1):69-71. doi:10.7326/M18-3197PubMedGoogle ScholarCrossref
    21.
    Bell  SK, Folcarelli  P, Fossa  A,  et al.  Tackling ambulatory safety risks through patient engagement: what 10,000 patients and families say about safety-related knowledge, behaviors, and attitudes after reading visit notes.  J Patient Saf. 2018;00(00):1-9. doi:10.1097/PTS.0000000000000494PubMedGoogle ScholarCrossref
    23.
    Wiebe  ER, Kaczorowski  J, MacKay  J.  Why are response rates in clinician surveys declining?  Can Fam Physician. 2012;58(4):e225-e228.PubMedGoogle Scholar
    24.
    Taylor  T, Scott  A.  Do physicians prefer to complete online or mail surveys? findings from a national longitudinal survey  [published online November 1, 2018].  Eval Health Prof. doi:10.1177/0163278718807744PubMedGoogle Scholar
    25.
    Sebo  P, Maisonneuve  H, Cerutti  B, Fournier  JP, Senn  N, Haller  DM.  Rates, delays, and completeness of general practitioners’ responses to a postal versus web-based survey: a randomized trial.  J Med Internet Res. 2017;19(3):e83. doi:10.2196/jmir.6308PubMedGoogle Scholar
    26.
    Cook  C, Heath  F, Thompson  RL.  A meta-analysis of response rates in web- or internet-based surveys.  Educ Psychol Meas. 2000;60(6):821-836. doi:10.1177/00131640021970934Google ScholarCrossref
    27.
    Blackstock  OJ, Moore  BA, Berkenblit  GV,  et al.  A cross-sectional online survey of HIV pre-exposure prophylaxis adoption among primary care physicians.  J Gen Intern Med. 2017;32(1):62-70. doi:10.1007/s11606-016-3903-zPubMedGoogle ScholarCrossref
    28.
    Keeter  S, Kennedy  C, Dimock  M, Best  J, Craighill  P.  Gauging the impact of growing nonresponse on estimates from a national RDD telephone survey.  Public Opin Q. 2006;70(5):759-779. doi:10.1093/poq/nfl035Google ScholarCrossref
    29.
    Curtin  R, Presser  S, Singer  E.  The effects of response rate changes on the index of consumer sentiment.  Public Opin Q. 2000;64(4):413-428. doi:10.1086/318638PubMedGoogle ScholarCrossref
    30.
    Kellerman  SE, Herold  J.  Physician response to surveys: a review of the literature.  Am J Prev Med. 2001;20(1):61-67. doi:10.1016/S0749-3797(00)00258-0PubMedGoogle ScholarCrossref
    31.
    U.S. Department of Health and Human Services. Summary of the HIPAA privacy rule. Published 2019. Accessed November 13, 2019. https://www.hhs.gov/hipaa/for-professionals/privacy/laws-regulations/index.html
    32.
    Patel  V, Johnson  C; The Office of the National Coordinator for Health Information Technology. Individuals’ use of online medical records and technology for health needs. Published 2018. Accessed July 29, 2019. https://www.healthit.gov/sites/default/files/page/2018-03/HINTS-2017-Consumer-Data-Brief-3.21.18.pdf
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