New medical notes system allows for patient input, increases engagement

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Allowing patients to write or add notes to their medical health records could keep patients more engaged in their care while also improving relationships with their physicians and reducing physician workload, according to a study published in the Annals of Internal Medicine.

The clinical documentation process often takes time away from the patient, leaving them feeling left out of their own care plan. To resolve the situation, researchers from UCLA Health and Beth Israel Deaconess Medical Center evaluated the feasibility of using the OurNotes platform to increase patient engagement. OurNotes allow patients to contribute to their own records, by adding symptoms or medical issue they experienced along with goals, rather than only viewing them.

"If executed thoughtfully, OurNotes has the potential to reduce documentation demands on clinicians, while having both the patient and clinician focusing on what's most important to the patient," said lead author Dr. John Mafi, assistant professor of medicine in the division of general internal medicine and health services research at UCLA. "Piloting OurNotes will start at four centers in 2018."

The study collected data regarding OurNotes from interviews with 29 healthcare professionals who had experience with OurNotes and included primary care physicians, specialists, nurse practitioners, information technology professionals and patient advocates. Overall, the healthcare professionals reported the OurNotes would be an effective tool in contacting patients before visits to review notes, provide additional history and list goals they would complete in the next in-office visit.

"One can argue that reading a note is far less active than actually participating in producing a note. Transforming practice with OurNotes holds great promise for more active patient involvement," said senior author Jan Walker, OpenNotes co-founder and assistant professor of medicine at Harvard Medical School. "We've had a warm reception from clinicians who want to give OurNotes a try. They are intrigued by the notion that an interval history and agenda provided by a patient is a way to streamline the visit and address the patient's priorities more effectively."