Optimal health care relies on accurate and effective communication, not only among doctors and medical staff, but also between the health care providers and their patients. In an effort to promote effective and efficient communication between clinicians and patients, Jan Walker, MBA, RN, and physician Tom Delbanco, MD developed the OpenNotes program, which is an emerging movement in which patients have access to the notes that health care providers, including doctors and nurses, write about them. The OpenNotes program thrives on transparency, patient-centered care, and meaningful communication in an effort to reduce medical errors and promote patient safety. Although health care providers and organizations often offer secure, electronic portals in which patients can book appointments online, communicate with their health care team via email, and obtain lab results, X-ray reports, and other test results, Walker says that these are only “data points.” “Having that data is fine,” Walker, a member of the research faculty of the Division of General Medicine and Primary Care at Beth Israel Deaconess Medical Center (BIDMC) and Harvard Medical School in Boston, and American Nurses Association (ANA) member, has said. “But if we expect patients to pick up the ball and be more involved in their health, they need all the information, their entire health story. And that means being able to see visit notes.” OpenNotes was first piloted in 2010 with primary care physicians at three, large health care organizations: BIDMC, Geisinger Health System in Pennsylvania, and the University of Washington Harborview Medical Center in greater Seattle. After a year, the OpenNotes team surveyed 105 physicians and more than 19,000 patients who participated in the program and found that 77 to 85 percent of patients reported understanding their health and medical conditions better by reading visit notes, and a similar percentage felt they were more in control of their health. Roughly three quarters reported taking better care of their health as a result of the additional information, and more than 20 percent reported sharing their notes with someone else, such as a family member or relative. Physicians generally reported stronger relationships with their patients, without a significant impact on their workflow, and agreed that opening their notes was a “good idea.” After the pilot program, OpenNotes expanded to include more health care professionals within the initial health systems, as well as in other health care systems. By December 2014, almost five million U.S. patients had been provided with online access to their notes, and parallel developments in health information technology have supported this spread, including government funding to increase use of electronic medical records. Like all electronic medical records programs, however, Open Notes is not without vulnerabilities. For instance, electronic medical records – like all data and information – are only as reliable as they are complete, accurate, and understood. If electronic medical information is not accurate or complete – whether due to misinformation provided by the patient or inaccurate documentation by doctors, nurses, or medical staff – the information can lead to medical errors such as misdiagnosis or mistreatment. In the event that there is a medical error, and medical malpractice may be involved, electronic medical records can provide critical information in proving the plaintiff’s case. In fact, in many cases, medical records are the key documentation to support a medical malpractice claim. If you were the victim of medical error, it is important to contact a lawyer as soon as possible in order to protect your legal rights and access any pertinent information. The Chicago medical malpractice law firm of Steinberg, Goodman & Kalish is dedicated to protecting the rights of medical malpractice victims and obtaining maximum financial recovery. If you have been the victim of medical negligence, contact the Chicago medical malpractice lawyers at Steinberg, Goodman & Kalish to schedule a free consultation to learn more about what to do following a medical error. Steinberg Goodman & Kalish (www.sgklawyers.com) is dedicated to protecting victims and their families. We handle medical malpractice, product liability, personal injury, wrongful death, auto accidents, professional negligence, birth trauma, and railroad law matters. Contact us at (888) 325-7299 or (312) 445-9084.
