Abstract

Background: Providers and policymakers are pursuing strategies to increase patient engagement in health care.

Increasingly, online sections of medical records are viewable by patients though seldom are clinicians’ visit notes

included. We designed a one-year multi-site trial of online patient accessible office visit notes, OpenNotes. We

hypothesized that patients and primary care physicians (PCPs) would want it to continue and that OpenNotes

would not lead to significant disruptions to doctors’ practices.

Methods/Design: Using a mixed methods approach, we designed a quasi-experimental study in 3 diverse

healthcare systems in Boston, Pennsylvania, and Seattle. Two sites had existing patient internet portals; the third

used an experimental portal. We targeted 3 key areas where we hypothesized the greatest impacts: beliefs and

attitudes about OpenNotes, use of the patient internet portals, and patient-doctor communication. PCPs in the 3

sites were invited to participate in the intervention. Patients who were registered portal users of participating PCPs

were given access to their PCPs’ visit notes for one year. PCPs who declined participation in the intervention and

their patients served as the comparison groups for the study. We applied the RE-AIM framework to our design in

order to capture as comprehensive a picture as possible of the impact of OpenNotes. We developed pre- and

post-intervention surveys for online administration addressing attitudes and experiences based on interviews and

focus groups with patients and doctors. In addition, we tracked use of the internet portals before and during the

intervention.

Results: PCP participation varied from 19% to 87% across the 3 sites; a total of 114 PCPs enrolled in the

intervention with their 22,000 patients who were registered portal users. Approximately 40% of intervention and

non-intervention patients at the 3 sites responded to the online survey, yielding a total of approximately 38,000

patient surveys.

Discussion: Many primary care physicians were willing to participate in this “real world” experiment testing the

impact of OpenNotes on their patients and their practices. Results from this trial will inform providers, policy

makers, and patients who contemplate such changes at a time of exploding interest in transparency, patient safety,

and improving the quality of care.

Keywords: Patient access to records, Electronic health records, Primary care physicians, Internet, Medical records,

Medical informatics, Patient participation