Coming Soon: Access to Your Medical Notes

Saturday, November 25, 2017 - 8:00am

What happens when patients are given greater access to their medical records, including the notes written by their doctors during each visit? At hospitals where that access is offered, patients report that they’re more involved in their own care, enjoy a greater sense of control, and are more likely to stick to their treatment plan and take their medications as prescribed.

Those benefits are the driving force behind an international movement called OpenNotes. It began in 2010, says Clinical Informatics Specialist Melissa Witt, BS, BSN, RN, and since then more than 19 million people have gained easier access to their medical notes.

Roswell Park is among the first hospitals in New York State to get on board. Very soon patients will be able to log on to their MyRoswell patient portal accounts to read the notes written by their doctors and other members of their medical team.

A Chance to Review Notes “in the Comfort of Their Own Homes”

Witt says the opportunity to read those notes can be especially important for cancer patients, who may forget what’s said during a clinic visit or when they’re being discharged from the hospital, because they’re nervous or simply overwhelmed with information. In fact, “patients forget between 40% to 80% of the information communicated during a visit,” according to the website of the nonprofit organization OpenNotes. “Patients and families report that ready access to notes reminds them about important next steps, tests and procedures, as they review what happened at the visit in the comfort of their own homes.”

Patients can also choose to share access to their notes with loved ones or caregivers, Witt explains. “Say you have an elderly patient whose child was not able to be with them during a visit. Instead of relying on the patient to relay what was talked about, the son or daughter can say, ‘OK, let’s look at your notes.’ They can log on and see exactly what was discussed.”

During preparations to introduce OpenNotes, Roswell Park learned that it was one of only eight hospitals in the state to win a $100,000 grant from the New York State Health Foundation to enhance the rollout of the program. Roswell Park was also awarded an additional $25,000 from the foundation. The funds will be used in part to conduct workshops led by clinical documentation experts to help healthcare staff improve their note-writing skills — for example, by writing in more patient-friendly language.

Patients Surveyed Say ‘Yes’ to OpenNotes

Special features will be built into the new notes system at Roswell Park, because we built our own portal rather than buying one-size-fits-all software, says Witt. “That sets us apart from some of the other hospitals that got this grant.” For example, while reading their notes, patients will be able to click a button and type a question into a box for their doctors to answer. Definitions will pop up when patients hover a mouse over the letters of medical terms and abbreviations that might not be familiar (for example, PSA, MRI or HX).

When Roswell Park’s OpenNotes program was still in the planning stage, Witt asked patients who serve on the Patient and Family Advisory Council whether they would be interested in reading the notes that are written during their medical visits. Twenty people responded, “and they told me what every study has told us: 100 percent said they would read the notes and would better remember their plan of care.”

The new program will start with patients in the GI Center, Urology Center, and Supportive Care and Survivorship Center, followed by the rest of the centers. Witt says that once OpenNotes is underway, Roswell Park will share its experience with other hospitals in Western New York, to extend the benefits to more patients throughout the region.

Patients may also request a hard copy of their Roswell Park medical records. Here’s how.