And it’s good. I think overall it’s going to be a good thing. [It] emphasize[s] what we have already been kind of introduced to in med school—that this … wall between patient and doctor is disappearing.
—A resident
A growing national initiative called OpenNotes is exploring the effects of inviting patients to view clinician progress notes (open notes).1 2 , 3 4 5 5 6
Despite these early positive experiences reported from faculty-level primary care physicians, little is known about the potential impact of open notes on graduate medical education (GME) and practice. In a process that may be unfamiliar to patients, trainee notes are typically written by a trainee and then reviewed, addended, and cosigned by a faculty member.7 8 , 9 10 11
On the basis of the results of the post-yearlong OpenNotes demonstration study,5
Method
We conducted a qualitative study of residents and faculty physicians at Beth Israel Deaconess Medical Center (BIDMC) in Boston, Massachusetts, and Geisinger Health System (GHS) in Danville, Pennsylvania. BIDMC is an urban academic medical center with 454 residents in 8 departments, as well as 174 fellows in 33 Accreditation Council for Graduate Medical Education (ACGME)-approved fellowship programs. GHS is a rural integrated health care delivery system with 325 residents within 21 ACGME-accredited residency programs and 60 fellows in 17 ACGME-approved fellowship programs.
For the purposes of this study, we defined all postgraduate trainees, including fellows, as “residents” for simplicity.
Recruitment
We conducted focus groups with residents and faculty physicians who supervise residents in spring 2013, prior to the implementation of open notes in the GME programs at each institution. We used purposive sampling to recruit volunteers from the programs.12
Group structure
We conducted separate focus groups for residents and faculty physicians to encourage open discussion. Experienced moderators from each institution facilitated the focus groups using a discussion guide (see Appendix 1), which we developed collaboratively, with some of us bringing experience from qualitative research (J.W., R.A.S., J.A.G., S.L.), and others bringing experience from medical education (S.K.B., B.H.C.), clinical informatics (B.H.C.), and medical ethics (S.K.B.). The discussion guide reflected both issues pertaining directly to open notes implementation in GME programs and broader concepts extrapolated from prior open notes studies.5 , 13 , 14
The institutional review boards of BIDMC and GHS reviewed this study and determined it to be exempt.
Analysis
We evaluated and interpreted the data using qualitative analysis methods described by Crabtree and Miller.15
Initially, investigators and project team members (B.H.C., S.K.B., J.W., M.A., L.M.F., R.M., J.A.G., D.N.C., R.A.S.) reviewed audio, field notes, and transcripts from each focus group at their institution individually, producing a list of key concepts. Each institution’s study team then met to discuss interpretations of the data using constant comparison and content analysis methods, revealing a series of codes (i.e., tags applied to portions of a transcript to catalogue concepts as they became apparent to the team15 , 16 16
Results
Thirty-six clinicians (24 [66.7%] residents and 12 [33.3%] faculty physicians) participated in one of seven focus groups at BIDMC or GHS. We conducted two resident focus groups and one faculty focus group at BIDMC, and three resident focus groups and one faculty focus group at GHS. Focus groups included representatives from primary care, general surgery, surgical and procedural specialties, and nonprocedural specialties. Overall, participants were ambivalent as to whether residents should participate in open notes, discussing in detail several potential risks and benefits. Four main themes emerged: (1) implications of full transparency, (2) note audiences and ideology, (3) trust between patients and doctors, and (4) time pressures.
Implications of full transparency: Will it help or harm?
Visible thought process.
Residents acknowledged that open notes enabled transparency by making their thought process more visible to patients. One resident noted: “And ultimately it will be a good thing. I think it will change the way we practice. People will see how things really operate within medicine.”
Residents added that allowing patients to see their thought process might be useful to them as a reliable source of information: “As opposed to what they are getting on WebMD … they are seeing my thought process.” One resident offered a unique analogy:
I kind of think of it like bedside rounding, when we round at the patient’s bedside rather than spending 30 seconds in that room and spending an hour outside of their room.… I like the idea—I think it would improve on my relationship with my patients for them to know that I spent this time on their note.
Residents and faculty physicians underscored that open notes could improve patient safety, engagement, and satisfaction. They thought that reinforcing information from visits could help patients, providers, and the informed consent process. One resident noted:
[In the] surgical setting … a lot of our appointments are mostly counseling about whether or not we think surgery would help the patient. And most of the time I am sure that a lot of the details just go right over their heads because it is such a dense conversation in such a little amount of time. So if they had the opportunity to read that … I think that would help someone to go back and remind themselves what we actually talked about….
However, a few faculty, particularly consultants, felt strongly that notes are the purview of clinicians, and were concerned that full transparency would change their content: “I want to make sure I can communicate [to] the referring physician…. Without sugar-coating it.”
Residents and faculty also identified several programmatic and educational benefits to the use of open notes and the transparency they would provide patients. Residents felt that transparency was the “wave of the future” and that training programs using open notes could be innovation leaders, preparing their trainees for future work settings:
There are a lot of places that are totally mesmerized by this kind of technology, and are going to be looking to roll it out at their institutions … and will be looking [to hire] people that have experience with it.
Improved note quality.
Residents thought note accuracy and quality might improve if clinicians knew patients were going to read the notes. Notes may be edited in more detail, which might reduce errors, and clinicians may reduce their use of the cut, copy, and paste functions in notes. One resident offered:
I think that patients also might find it interesting how much of their notes by certain providers are copied and pasted, and they might be—at least if I was a patient I would be—a little bit upset about that. And that might actually be a positive thing.
Residents and faculty also remarked that allowing patients to see notes may result in a powerful check on the use of pejorative or judgmental language in notes. “I think it would be more respectful for patients if we have this sort of collaborative relationship where we get the judgment out of it,” one faculty physician noted.
How much to share?
Residents were unsure how much information to share with patients in notes. They described a tension between balancing sensitivity to patients and accuracy of medical information. Residents were particularly worried about how to document sensitive issues such as obesity, substance abuse, sexual histories, and the possibility of cancer or other conditions with grave prognoses. One resident commented:
Written words are hard to interpret and I put in a lot of different diagnoses and we go with a lot of scary diseases and I don’t want somebody coming up and being like, “You think I have Alzheimer’s,” or “You think I have Parkinson’s.” No, I don’t—you just, you could, possibly—maybe—you know.
A few residents were concerned about being able to predict what would offend patients. As one attested: “Sometimes we have diagnoses which we feel are no big deal at all. And the patients, for whatever reason just latch on to it and it’s earth-shattering.” Still, some faculty physicians noted that open notes help facilitate transparent communication; as one added, “It’s rare that I have something that is a secret in my note that I haven’t shared with the patient.”
Nuance.
Residents and faculty physicians alike discussed nuance in note writing, referring to subtle differences in wording that can have a large impact on readers, including patients, insurers, lawyers, and others. When discussing how much information residents document, one faculty physician said: “Mostly too much, sometimes too little. Some residents … don’t understand the nuance.” Some residents and faculty feared that without navigating nuance effectively—a skill largely learned on the job—resident note writing may offend patients, have negative consequences for insurance or worker’s compensation, or become vaguer.
The power of print.
Residents felt unsure about whether the net effect of seeing conditions written down would be helpful or harmful to patients or the patient–doctor relationship. “I don’t know if that would inhibit communication,” one resident offered, “because then [patients] would be able to see these things in black and white.” Other residents thought direct communication could benefit patients, with one resident commenting:
People tap dance around it. And they’ll say, well, you know, you’re a little on the heavier side, this or that. And when you see it there in black and white, this patient is morbidly obese. They have X, Y, and Z conditions related to it. Maybe that’s helpful to some people.
Literacy/Disparities.
Residents thought open notes would more likely benefit highly literate and affluent patients than underserved patients, potentially exacerbating health care disparities and the “digital divide.”17
If we are saying as an institution that this is something that is good for patients and [our clinic], and might be good for patient outcomes, [then] we should try to incorporate a way to include non-English-speaking patients, low health literacy patients, and just think about what it will mean for them to be involved in this project, and how we can do it.
Note audiences and ideology: Who is the note for?
Ideal purpose and audience of a note.
Many residents and faculty physicians lamented that notes already serve too many audiences and worried about adding patients as another audience. They primarily viewed the note as a vehicle for communication between providers and preferred that notes remain clinical and scientific. Some residents and faculty were resentful of the idea of writing notes in layperson terms. One faculty physician commented:
So after all this education and medical school and training … why should I write my notes to be read by somebody who may have elementary school reading.… I think that would be a disfavor to me as a specialist communicating to other physicians.
Others, such as this resident, added, “I think it’s key for patients to understand that they are getting a glimpse of a medical record that serves another primary purpose.”
Inherent educational value of a note.
Recognizing that notes are educational tools in training programs, some residents wrestled with how to balance their educational needs against the needs of the patient:
So you included cancer or HIV or that kind of black cloud diagnosis … and you don’t want the patient to get anxious about [it], but you include it in there because you want to prove someday that you were thinking about it and then you had a plan for it.
While another resident commented, “You will be more concerned about writing the note in a way that the patient is going to understand rather than focusing on what you are doing.”
On the other hand, faculty physicians suggested that open notes may enhance communication with patients as well as the educational experience of difficult conversations, because doctors will feel more compelled to discuss what they are writing. In addition, residents suggested that open notes could boost faculty feedback: “It would be nice if someone else was eyeballing [notes] under the pretext of ‘Yikes, the patient is going to see this.’” Residents added that open notes may also provide a new opportunity for feedback from patients: “You could get some aggregate data on how your patients actually feel about how you are [doing] … I’ve never actually seen any of that stuff coming back to me.”
Trust between patients and doctors: How will it change?
The patient–doctor relationship.
Residents voiced uncertainty about how open notes would affect their relationships with patients. Some residents anticipated benefits, noting: “I think they will appreciate that open communication,” and “They are entitled to what we think about them … sometimes the truth may be useful to them.” Another resident commented: “I think it has the capability to really engage people. Even if it’s things that they don’t understand, things that they disagree with, you are still engaging them.”
But some residents worried that mistakes, confusing terminology, or judgmental language could reduce trust. One resident noted having “the worry that everybody has, and anxiety, that it might make your relationship either in some way adversarial if [patients] don’t like the language that you’re using.” In particular, incorrect diagnoses may be problematic. One resident noted, “Things that residents write, especially early in their training, could be wrong and therefore confusing to the patient and even create a poor relationship.” Residents also worried that patients concerned about how much will be written down verbatim may self-censor their history: “[It] brings up the possibility that the patient might not be as honest with you.”
Faculty physicians imagined changes in patient–doctor relationships if notes were posted by patients on social media: “It’s a generational question.… I can see my children with social media and maybe this [note is posted] on my Facebook page—you know, my medical record. I know that’s going to happen.”
Liability.
Some residents and faculty physicians worried that easy access to notes could facilitate malpractice claims. One resident wondered: “Would there be some outcome … that the patient would then go back through their records, or their notes from many years back and sort of scour the system, and create more investigation and potentially more litigation from that.”
One faculty physician commented:
One of these fabulous TV lawyers [will be] there to say, “Did you ever read your open notes? If they don’t make sense to you, give me a call.” They have a case. That’s the reality of what the world is.
Still other faculty felt “It [wouldn’t] really change the game,” suggesting that litigious patients will exist irrespective of open notes, and patients already have legal access to their record.
Different patient populations.
Alluding to different levels of underlying trust, residents suggested that sharing notes might work better with some patient populations than with others:
In … our resident practice, we have a series of patients that are more like continuity patients … who I would feel more comfortable having access to my notes, because we have this relationship. And then we have … urgent care [patients] … and somehow those clinic visits are more difficult because the expectations off the bat are different. And those are, in my mind, the ones that I wouldn’t want to open.… In my mind, I have two patient populations.
Time pressures: What effects will open notes have on workflow?
Resident fatigue and fear of change.
Universally, residents and faculty physicians noted increasing time pressures and worried about the workflow impact of open notes. Residents felt they were downstream of all care tasks, and particularly vulnerable: “Residents, I think, are particularly terrified that something is going to change and it’s going to make our life worse.”
Concerns about responding to patient queries about notes evoked a sense of underlying burnout among residents: “It’s just every time a patient opens their mouth, it is something else I have to take care of.… I just don’t have time, so that really is anxiety-provoking for me.” Another resident commented:
When I have talked with my colleagues and peers about it, a lot of the anxiety stems from just that … we are afraid that this is going to trigger some catastrophic level of worry in our patients that is just going to be another fire that we have [to] put out.
However, one resident advocated that if faculty were participating, residents should too: “[Patients] go and see another doctor, and now all of a sudden they can see that note, but can’t see my note. I work hard enough to make myself seem like a real doctor.”
Faculty overburden.
Faculty physicians expressed stress about a lack of time as they acknowledged that with open notes they would need to more carefully review residents’ notes to catch any mistakes or judgmental language before the patient reads them. One faculty physician commented: “We are paid based on productivity. I would have to cut back on my productivity in order to thoroughly read every part of every resident note.” Another faculty physician noted:
You are given a 10-minute window of time in which to see this patient, discuss this patient, and direct the resident/fellow, as to what the plan of action needs to be; then together go into the room and talk to the patient. And now you want to be able to sit and scrutinize every word written in a note. That doesn’t fit the template. That’s a huge problem.
Faculty highlighted the tension between providing residents feedback and educational opportunities to adjust, modify, or correct their notes and having notes signed in a timely manner: “I understand there’s a teaching component to this that returning [notes] makes [residents] responsible to think about it. But at the same token with this new time constraint [for signing notes], come on.”
Potential benefits and recommendations
Despite their concerns, residents and faculty physicians noted several specific potential benefits of open notes for patients, residents, GME training programs, and health care systems (Table 1 ). They also offered several specific recommendations for implementing open notes within GME training programs (Table 2 ). Recommendation suggestions ranged from the pedagogical to the practical. Most residents and faculty endorsed setting expectations with patients, including a systematic and practice-supported way of educating patients about notes, why typos may exist, and what the process should be for handling note-related inquiries. Residents raised the idea of patients contributing to the note (providing the history of present illness, for example) if it would save time. Some residents and faculty advocated an “intern delay”—exempting new interns from participation—while others argued this would be impractical given cross-cover responsibilities between residents and resident turnover every few years, both of which could create gaps in patients’ access to notes.
Table 1: Potential Benefitsa of Open Notes in Graduate Medical Education (GME), by Beneficiary, Qualitative Study on Open Note Implementation, Beth Israel Deaconess Medical Center and Geisinger Health System, Spring 2013b
Table 2: Summary of Residenta and Faculty Physician Recommendations for Implementing Open Notes Within Graduate Medical Education Training Programs, Qualitative Study on Open Note Implementation, Beth Israel Deaconess Medical Center and Geisinger Health System, Spring 2013b
Residents observed that notes themselves may need to evolve. Recognizing that while the practice of medicine has changed vastly over the last century, one resident remarked: “For a hundred years medical students have learned how to write notes to communicate with other doctors. And now this has changed, where notes are also given to patients. Should medical students and/or residents learn to write notes differently?”
Discussion
As medical record transparency through secure electronic patient portals gains momentum, we explored the attitudes of residents and faculty physicians about sharing residents’ notes with patients. We found a great deal of ambivalence, as our participants voiced uncertainty about how transparent to be in notes, how to balance the many purposes notes serve, effects on trust and the patient–doctor relationship, and effects on time management in an already demanding workflow. Many of the concerns voiced by our participants mirrored those of previously surveyed faculty-level primary care physicians, such as concerns about having enough time to devote to writing notes, professional liability, and too many note audiences.14 Table 1 ). Bringing these attitudes to light can help GME programs considering open notes to anticipate and address concerns while cultivating potential benefits.
Our results led to three insights. First, participant comments highlighted that transparency can be a catalyst for needed change in medicine.18 19 and his or her care team. Similarly, the motivation to abate copy-and-paste practices,20 21 22 23
Second, although trust is traditionally viewed through the lens of patients trusting doctors,24 25
Third, sharing notes with patients may help shape medical education in new ways. The issues raised by open notes extend beyond note writing, into the actual practice of medicine. Simply put, transparent records will require transparent doctoring. Open notes may encourage more open discussion with patients about difficult topics—a skill central to medical education. In addition, open notes may emphasize the value of learning from patients. Residents may find that answering patient questions about notes provides insights about how well they communicated and how well the patient understood their plan. As organizations increasingly emphasize interprofessional learning, transparent records may also serve as a “hub” linking doctors, nurses, pharmacists, and other team members. As patients turn to different team members with questions, the note may become a shared platform through which to more actively integrate interprofessional team members in their patient education efforts.
Opening residents’ notes to patients invites creative consideration of new frontiers and challenges in medical education. For example, as residents suggested, why not have patients provide feedback on notes written by residents, enabling a patient role in medical education?26 , 27 28
Bringing open notes to GME training programs will raise important questions for the medical education community. How honest should notes be? Can trainees’ notes be shared with patients while maintaining a safe learning environment? What are the educational implications of training doctors to trust and engage their patients? Can open notes provide a new platform for the assessment of competencies like communication and professionalism that are traditionally more difficult to evaluate? And finally, what does the ideal note of the future look like, who should it be written for, and how should medical students be taught to write notes?
Many of the resident concerns we uncovered mirrored those of attending physicians who participated in the baseline OpenNotes survey.14
Study limitations include voluntary participation, which could mean that our participants were subject to selection bias. In addition, the study was conducted at two institutions pioneering sharing notes with patients, which may have influenced participant views. However, we feel that we were able to obtain a balanced set of concerns and benefits from a diverse group of participants. Lastly, despite involving two sites, the total number of participants was small. However, discussions were rich and we noted thematic saturation, and as open notes implementation proceeds at both institutions, we have found that our themes have encompassed spontaneously arising issues.
In conclusion, residents and faculty physicians identified clinical and educational benefits to open notes in GME but were concerned about potential effects on the patient–doctor relationship, requirements for oversight, and increased workload and burnout. Regardless of these concerns, some residents thought they should be included in open notes if faculty physicians were participating. Open notes may catalyze transparency and accountability to patients, promote patient engagement, and yield better notes and enhanced feedback, but they may also require physicians to trust their patients.
Acknowledgments: The authors would like to thank the graduate medical education leaders at each site and the residents and faculty who participated in the focus groups for sharing their perspectives and educational insights. We are especially indebted to Carrie Tibbles, Tara Kent, Eileen Reynolds, and Chris Smith for their support.
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Appendix 1 Discussion Guide Used in a Qualitative Study on Open Note Implementation in Graduate Medical Education, Beth Israel Deaconess Medical Center and Geisinger Health System, Spring 2013a b
Patient–doctor relationship and communication, benefits, and drawbacks
Global attitudes
Are you generally familiar with OpenNotes? (If not, describe the concept of electronically available clinician progress notes. If yes, ask for initial reactions. Specify that going forward, we will discuss specifically residents’ notes, not OpenNotes in general.)
The hospital is committed to providing open notes through PatientSite to all patients for all encounters with medical personnel (including MDs [including trainees], RNs, social workers, physical therapists, etc.). Do you think residents’ notes should be made available to patients? (Why or why not? )
If not, what might make you more comfortable with open notes?
How might opening residents’ notes be helpful to patients?
How might open notes be helpful to you as a resident?
Hurtful?
Prompts: work life, education
How might your notes affect your relationship with patients? How do you anticipate open notes will affect your patients’ communication with you?
Do you think open notes will have any effect on patient safety?
How do you feel about the possibility of patients discovering errors in your notes? What concerns do you have about errors in notes?
What changes or options might mitigate these concerns?
Workflow concerns specific to training status
Anticipated workflow concerns
What workflow issues do you believe should be addressed before the implementation of open notes in your department?
Prompt: response for other disciplines
Prompt: cross-coverage
One of the ways that residents’ notes are different from other providers’ notes is that they are cosigned and may have addenda from preceptors. Do you think the attending’s cosignature or addendum on your note will have any impact on your relationship with your patients?
Prompt: autonomy, contact, credibility
How do you think patient questions about your note should be handled? (Who should be contacted? Who should respond?)
Effect on educational goals
How might open notes impact your education at Beth Israel Deaconess Medical Center or Geisinger Health System? Do you think open notes will make you a better clinician? In what ways?
Do you see any new educational opportunities stemming from open notes?
Prompts: feedback from patients; more thorough faculty feedback on notes; educational focus on note writing, communication, and transparency; etc.
What specific training or support might be helpful for you as open notes goes forward?
For faculty physicians
Faculty physician attitudes
The hospital is committed to providing OpenNotes to all patients for all encounters with medical personnel (including trainees, faculty MDs, RNs, social workers, physical therapists, etc.). Do you think residents’ notes should be available to patients on OpenNotes? (Why or why not?)
How do you think open notes will change your preceptor role? How do you think open notes will affect patient safety?
How do you think open notes will affect your residency program?
Prompts: recruitment, safety, branding, educational focus or goals
How do you anticipate open notes will impact rotating residents in your training programs? What policies or procedures, if any, should be implemented to accommodate rotating residents?
a The authors conducted focus groups with 36 clinicians (24 [66.7%] residents and 12 [33.3%] faculty physicians) to (1) identify resident and faculty physician attitudes about sharing residents’ notes with patients, and (2) assess specific educational needs, policy recommendations, and approaches to facilitate open note implementation. Residents ranged from postgraduate year 1 to postgraduate year 4 residents and, for the purposes of this study, also included fellows. Cited Here
b Italicized questions were prioritized in case discussion groups were not able to discuss all topics in the allotted time (between 60 and 90 minutes).Cited Here
