The next step in shared decision-making: Let patients contribute to medical notes

A stethoscope on a computer keyboard
Researchers explore whether OurNotes is the next step in patient engagement. (Getty/anyaberkut)

You’ve no doubt heard of OpenNotes, but is the next step OurNotes, where patients actually contribute to their doctors’ notes?

Studies have shown the value of OpenNotes to patients, including the ability to help them confirm and remember the next steps in their care and allowing the sharing of information with care partners. But in a report in the Annals of Internal Medicine, researchers explored the idea of allowing patients and families to co-produce medical notes with clinicians.

Clinicians are increasingly inviting patients to read office visit notes on secure electronic portals, a practice intended to improve communication, patient engagement and patient safety, said the researchers from the University of California, Los Angeles, Beth Israel Deaconess Medical Center and Harvard Medical School. While reading notes is valuable, it’s a passive activity, they said, raising the question of whether the next step is to have clinicians invite patients and families to contribute to their notes to further patient engagement and take work off of busy doctors.

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Their report detailed ideas from experts who were asked about the concept of OurNotes, which would allow patients to write medical notes, along with clinicians. The researchers did 30-minute interviews with 29 healthcare experts, including 11 primary care doctors, two specialist doctors, nurse practitioners, health information technology professionals, patient advocates and a policy expert.

Participants supported the idea, which they said would be most valuable before scheduled office visits. The most popular intervention was the idea of patients writing an interval history and formulating goals for an upcoming visit. “I have an agenda. My patient has an agenda as well and we don't share that with each other until we get to that precious 20 minutes in the office,” said one respondent. “Negotiating a visit agenda before visits, I think, will be useful.”

The experts also offered a couple of caveats, including that patient contributions to medical records must not increase clinician workload. Some also wondered if the idea of OurNotes might impose unaccustomed and unwelcome accountability on some patients, who would be uncomfortable with the idea.

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