The Doctor’s Note Is In

Dr. Mitchell Adler (center) and medical students consult with patients at the Hofstra Northwell Free Clinic.

Sharing is quality caring according to users of OpenNotes®, a national movement to bring more transparency to medical records by giving patients access to the visit notes written by their doctors, nurses, or other clinicians.

In fact, evidence from a 2010 study involving 100 primary care physicians from three U.S. medical institutions suggests that disclosing visit notes to patients may make healthcare practice more efficient, improve communication, and help patients become more actively involved with their medical care.

Today the initiative has been implemented at more than 40 medical centers across the country, and testing of the program is underway throughout Northwell Health clinical practices as well as the Hofstra Northwell School of Medicine Free Clinic in Rego Park, New York. The OpenNotes pilot at Northwell and the free clinic began on October 1, 2016—so far over 1,300 notes have been made available to patients.

“Healthcare providers have the option of allowing office notes to be delivered to the patient portal, FollowMyHealth®—the program is completely under the physician’s control,” explained Mitchell Adler, MD, FACP, assistant professor of medicine at Hofstra Northwell and spearhead of the OpenNotes effort. “It is an opportunity to stimulate further patient engagement for the purpose of improving the health care delivery and outcomes.”

OpenNotes at Work

Patients must be enrolled in FollowMyHealth to gain access and utilize OpenNotes. Portal users can read details of their office visit from their personal computer, tablet, or smart phone.

Following an appointment, a note is created by the healthcare provider using a template in which all communication and directives during the visit are recorded. The note is sent to the portal by way of a prompt—it is not delivered automatically. By logging into the portal, the patient can review a summary and explanation of the visit, including details like medical history, next steps and results for lab work, X-rays, MRIs and related exams, dosage for medications, as well as the clinician’s assessment. Patients can respond with questions or concerns to their healthcare provider online, by phone, or during the following visit. Such transparency builds trust between the physician and patient.

“The program helps to enhance the doctor-patient experience by allowing individuals the ability to keep close tabs on their health,” said Dr. Adler, who serves as chief medical informatics officer at Northwell Health Physician Partners. “It fully involves patients from diagnosis to decision about their care and treatment plan.”

Research has shown that by reading their notes, patients are better able to remember their doctor visit and discussion, take control of their care, and are more compliant with treatment. In turn, doctors can promote patient and caregiver education, communication, and preparation. Healthcare providers can also meet patient demand for access to medical records.

“We’re still in the process of rolling out the program, but I believe it will exceed expectations for all involved,” said Dr. Adler. “Our medical students working within the free clinic will graduate already knowing how to use this communication tool that will become the standard of care—it is a positive push in the right direction for clinicians, learners, and patients.”

For more information about OpenNotes, please contact Dr. Adler or visit www.opennotes.org

About the Hofstra Northwell School of Medicine

Established in 2008, the Hofstra Northwell School of Medicine (formerly, Hofstra North Shore-LIJ School of Medicine) is the first allopathic medical school to open in New York State in more than 40 years. Hofstra University and Northwell Health are partners in the founding and operation of the School of Medicine, an institution built upon the strong clinical and graduate medical education programs of Northwell, as well as the robust research and academic programs of both Hofstra University and Northwell’s Feinstein Institute for Medical Research.  

In February 2015, the School of Medicine received full accreditation from the Liaison Committee on Medical Education (LCME), an important national designation for meeting established standards in medical education, followed by a highly successful residency placement and graduation of the medical school’s charter class in May 2015.

Currently, the School of Medicine is comprised of more than 2,400 faculty members across 25 academic departments, and enrolls a diverse community of 400 students.

About Northwell Health

Northwell Health is New York State’s largest health care provider and private employer, with 21 hospitals and over 500 outpatient practices. We care for more than 1.8 million people annually in the metro New York area and beyond, thanks to philanthropic support from our communities. Our 61,000 employees – including 15,000+ nurses and 2,500+ doctors within Northwell Health Physician Partners – are working to change health care for the better. We’re making breakthroughs in medicine at the Feinstein Institute. We're training the next generation of medical professionals at the visionary Hofstra Northwell School of Medicine and the School of Graduate Nursing and Physician Assistant Studies. And we offer health insurance through CareConnect. For information on our more than 100 medical specialties, visit Northwell.edu.