Tom Delbanco, MD (*); Jan Walker, RN, MBA (*); Sigall K. Bell, MD; Jonathan D. Darer, MD, MPH; Joann G. Elmore, MD, MPH; Nadine Farag, MS; Henry J. Feldman, MD; Roanne Mejilla, MPH; Long Ngo, PhD; James D. Ralston, MD, MPH; Stephen E. Ross, MD; Neha Trivedi, BS; Elisabeth Vodicka, BA; Suzanne G. Leveille, PhD, RN
* Dr. Delbanco and Ms. Walker contributed equally to this manuscript.
Acknowledgment: The authors thank Elaine Bianco, BSN; Carolyn Conti, BS; Christopher Dries, BA; James I. Hoath, PhC; Margaret Jeddry; Jing Ji, MS; J. Andrew Markiel, PhD; Lawrence Markson, MD, MPH; Natalia Oster, MPH; Lisa M. Reich, PhD; Joan Topper, BS; Qiang Wang, MD; and Clara De La Cruz Watral, MBA, for invaluable contributions to this project. They also thank the many patients and doctors who both took a chance and participated actively in OpenNotes.
Grant Support: All investigators were supported by The Robert Wood Johnson Foundation's Pioneer Portfolio grant 65921. Dr. Delbanco and Ms. Walker were also supported by the Drane Family Fund and the Richard and Florence Koplow Charitable Foundation. Dr. Elmore was also supported by the National Cancer Institute (K05 CA 104699).
Potential Conflicts of Interest: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M12-0737.
Reproducible Research Statement:Study protocol, statistical code, and data set: Not available.
Corresponding Author: Jan Walker, RN, MBA, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215; e-mail, email@example.com.
Current Author Addresses: Dr. Delbanco, Ms. Walker, Dr. Bell, Ms. Farag, Dr. Feldman, Ms. Mejilla, Dr. Ngo, and Ms. Trivedi: Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215.
Dr. Darer: Geisinger Health System, Danville, PA 17822.
Dr. Elmore and Ms. Vodicka: Harborview Medical Center, University of Washington School of Medicine, Seattle, WA 98104.
Dr. Ralston: Group Health Research Institute, Group Health Cooperative, Seattle, WA 98101.
Dr. Ross: University of Colorado, Aurora, CO 80045.
Dr. Leveille: College of Nursing and Health Sciences, University of Massachusetts, Boston, MA 02125.
Author Contributions: Conception and design: T. Delbanco, J. Walker, J.D. Darer, J.G. Elmore, H.J. Feldman, J.D. Ralston, S.E. Ross, S.G. Leveille.
Analysis and interpretation of the data: T. Delbanco, J. Walker, S.K. Bell, J.G. Elmore, R. Mejilla, L. Ngo, J.D. Ralston, S.E. Ross, S.G. Leveille.
Drafting of the article: T. Delbanco, J. Walker, S.G. Leveille.
Critical revision of the article for important intellectual content: T. Delbanco, J. Walker, S.K. Bell, J.G. Elmore, R. Mejilla, L. Ngo, J.D. Ralston, S.E. Ross, S.G. Leveille.
Final approval of the article: T. Delbanco, J. Walker, S.K. Bell, J.D. Darer, J.G. Elmore, N. Farag, H.J. Feldman, R. Mejilla, L. Ngo, J.D. Ralston, S.E. Ross, N. Trivedi, E. Vodicka, S.G. Leveille.
Provision of study materials or patients: T. Delbanco, J. Walker, S.K. Bell, J.D. Darer, J.G. Elmore, N. Farag, L. Ngo, J.D. Ralston, S.E. Ross, N. Trivedi, E. Vodicka, S.G. Leveille.
Statistical expertise: R. Mejilla, L. Ngo, S.G. Leveille.
Obtaining of funding: T. Delbanco, J. Walker.
Administrative, technical, or logistic support: N. Farag, H.J. Feldman, N. Trivedi, E. Vodicka.
Collection and assembly of data: J. Walker, N. Farag, H.J. Feldman, R. Mejilla, N. Trivedi, E. Vodicka, S.G. Leveille.
Delbanco T, Walker J, Bell SK, Darer JD, Elmore JG, Farag N, et al. Inviting Patients to Read Their Doctors' Notes: A Quasi-experimental Study and a Look Ahead. Ann Intern Med. 2012;157:461-470. doi: 10.7326/0003-4819-157-7-201210020-00002
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Published: Ann Intern Med. 2012;157(7):461-470.
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David L. Fischman, MD, Howard H. Weitz, MD
Thomas Jefferson University Hospital, Philadelphia, PA
October 23, 2012
Culture of Transparency and Safety
There has been much in both the lay and medical press of late about safety or lack thereof in medicine. In a recent excerpt from his book “Accountability”, published in the Wall Street Journal (September 22,2012), Dr. Marty Makary claims that hospitals are unsafe and that each year 98,000 hospital deaths occur from medical errors. In his article, Dr. Makary provides twenty-year-old data to support his claim that there is a lack of accountability on the part of hospitals and physicians in the care of patients leading to medical errors and excess mortality. He touts several ideas with the presumption that they can improve the safety within hospitals. One of these concepts is “Open Notes”, where patients have access to their doctor’s notes. It is with excellent timing that the Annals of Internal Medicine published “Inviting patients to read their doctor’s notes: A Quasi-experimental study and a look ahead” (Delbanco T., et al. Oct 2,2012). In this study, the authors describe a practice of facilitating patient access to doctor visit notes via electronic link. With this means, patients felt more in control of their care and an increase in compliancy with the recommendations of their physicians, including medications. While the issue of safety was not specifically addressed, the concept of open notes should lead to improved patient safety. Contrary to the beliefs of Dr. Markary, Delbanco et al bring to light that American medicine has been quietly, but forcefully laying the groundwork for a culture of improved transparency that may enhance patient safety. It is time that we make our patients aware of what has already been done or is being done on their behalf and enlist their assistance in further studying the benefits as well as risks of patient access to the medical record. This is the least that we can do to move the culture of safety forward. In the meantime, patients need to know that although their records belong to the hospital or physician practices, they are accessible to them. They can and should ask to see their medical records so that they know that nothing is being hidden from them.
Hayward Zwerling, M.D. FACP, FACE
Lowell Diabetes & Endocrine Center
February 24, 2014
Patient Web Portals, OpenNotes: Utilization Rates in a Small Medical Practice
In 2012, three institutions decided to allow their patients to read their physicians’ progress notes (OpenNotes) via their institution’s patient web portal (1). The patient participation rate varied markedly among the three institutions: 47%, 84% and 92%. At the conclusion of the quasi-experiment, 99% of patients wanted to continue to have access to their progress notes and all physicians choose to continue in the OpenNotes project.
In response to that article, my office decided to allow our patients to read their progress note via our EMR’s patient web portal. My offices consist of two endocrinologists, one of whom does some primary care. Information about our patient web portal is prominently displayed in the exam rooms, waiting room and patient’s are encouraged to access our patient web portal by the front desk person and the physicians.
We recently our 2013 patient web portal statistics and found a much lower patient participation rate than was cited in the OpenNotes experiment.
In 2013, we saw a total of 2,322 unique patients and there were a total of 4,169 office visits. 13.7% of the patient’s accessed our patient web portal for any reason, which could have been to review their problem list, medicine list, allergy list, lab results, email their physician, pay a bill or to request a prescription refill. Only 4% of patients elected to read their progress notes.
Recently, there has been a push to get patients to utilize patient web portals as a means of encouraging patient engagement in the hope that that this will have a salutary effect on the healthcare system. A recent systematic review by Goldzweig et al(2) look at this issue and concluded “…we consider it unlikely that patient portals will have substantial effects on utilization or efficiency, at least in the near term…”
Although it remains unknown whether patient web portals and OpenNotes will eventually have a beneficial effect on the healthcare system, the data derived from one small medical practice, which is representative of a large fraction of US medical practices, would suggest that only a very small percentage of patients will use a patient web portal (for any reason) and an even smaller percentage will read their progress notes online. This fact would appear to support Goldzweig et al’s conclusion that patient web portals may not have a salutary effect on the healthcare system and societal resources should probably be redirected in another direction.
1. Tom Delbanco, MD et al. Inviting Patients to Read Their Doctors’ Notes: A Quasi-experimental Study and a Look Ahead. Ann Intern Med. 2012;157:461-470.
2. Caroline Lubick Goldzweig, MD, MSHS et al. Electronic Patient Portals: Evidence on Health Outcomes, Satisfaction, Efficiency, and Attitudes A Systematic Review. Ann Intern Med. 2013;159:677-687.
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