OurNotes: Patients and Clinicians Creating Notes Together

What is OurNotes?

OpenNotes has been exploring a new way to improve communication and shared decision-making through a research initiative called “OurNotes.”

OurNotes has two principal goals:

1. To engage patients more actively in their care, and
2. To help make visits more focused and efficient for patients, care partners, and clinicians

OurNotes draws on the insights of Lawrence Weed, MD, creator of the “SOAP” notes well-known to clinicians. It asks patients to compose an interval history, the “S” (subjective) component of a note, and to express their goals for a visit.

The hypotheses: OurNotes will:

1. increase patient engagement
2. bring more focus and structure to encounters
3. promote shared decision-making, and
4. off-load some work from clinicians

OurNotes draws on the “SOAP” notes well-known to clinicians and asks patients to compose an interval history, the “S” (subjective) component of a note, and express their goals for a visit..—Tom Delbanco, MD, MACP

The OurNotes process for patients

Prior to a scheduled visit, patients are asked to review their prior open notes, and then to:

1. Prepare and submit a brief (300 words or less) interval history describing how things have gone since a previous visit, and
2. Prepare and submit their 2 or 3 most important goals or questions for the visit

Patients send the OurNotes pre-visit forms to an electronic health record (EHR) through secure, Internet patient portals on which they have registered. The content of the forms then becomes part of their medical records, with mechanisms varying according to the local EHR system.

The OurNotes process for clinicians

Clinicians review the patients’ submissions prior to or during visits, and then either refer to them or incorporate them into the visit note itself.

Telemedicine and OurNotes

With the rapid adoption of telemedicine triggered by the Covid-19 pandemic, in addition to preparing their narrative histories and goals, patients are including some of the “pre-work” typically performed by medical assistants prior to face to face visits.

The OurNotes pre-visit forms ask patients to update medications they are taking and to indicate which need to be refilled. In addition, if feasible for the individual or family, patients submit their weight, temperature, blood pressure, and even their blood sugar or oxygen saturation if indicated.

OurNotes for Care Partners (caregivers)

With OurNotes for Care Partners (ONCP), we are piloting and evaluating an initiative designed to identify, engage, and support care partners in clinical settings. Similar to OurNotes, patients are asked to complete a pre-visit questionnaire to alert providers to major changes in their lives and to set the agenda for an upcoming visit. ONCP goes a step further and asks those patients if they have caregiving responsibilities. Patients identifying themselves as care partners are provided a link to the ARCHANGELS “Caregiver Intensity Index” (CII), a two-minute questionnaire that allows them to assess their level of caregiver stress, what is going well, and where they could use more support. Upon completing the CII, they can explore and access through the ARCHANGELS website resources tailored to their location. They can choose to report their CII score back to their clinician. The OurNotes and care partner responses become available to the clinician to review ahead of the visit and discuss with the patient.

OurNotes so far…

The patients and doctors participating in OurNotes pilot programs have offered positive reports, and the practice is now spreading rapidly, both for telemedicine and in-person visits.

OurNotes & OurNotes for Care Partners project team

Principal Investigators

Cait DesRoches, DrPH, Executive Director, OpenNotes, Associate Professor of Medicine, Harvard Medical School and Beth Israel Deaconess Medical Center†

Jan Walker, RN, MBA, Co-Founder, OpenNotes, Associate Professor of Medicine, Harvard Medical School and Beth Israel Deaconess Medical Center*

Co-Investigators

Jessica Ameling, MPH, Research Area Specialist, University of Michigan Internal Medicine-General Medicine†

Aysel Cibildak, MBA, Business Development and Client Services, ARCHANGELS†

Tom Delbanco, MD, MACP, Co-Founder, OpenNotes, John F. Keane & Family Professor of Medicine, Harvard Medical School and Beth Israel Deaconess Medical Center*†

Joe Dong, MS, Biostatistician, OpenNotes, Beth Israel Deaconess Medical Center*†

Alex Drane, CEO, ARCHANGELS†

Matt Germak, MD, MPH, Chief Quality and Safety Officer, Beth Israel Lahey Health Primary Care*

Sara Jackson, MD, MPH, Director, Adult Medicine Clinic, Harborview Medical Center, Associate Professor of Medicine, University of Washington School of Medicine*

Gila Kriegel, MD, Internist, Beth Israel Deaconess Medical Center, Assistant Professor of Medicine, Harvard Medical School*

Suzanne Leveille, RN, PhD, Professor, University of Massachusetts*

CT Lin, MD, Chief Medical Information Officer, UC Health, Professor of Medicine, University of Colorado School of Medicine*

Stephen Liu, MD, MPH, Internist, Dartmouth Hitchcock Medical Center, Associate Professor of Medicine, Dartmouth Geisel School of Medicine*

Jennifer Meddings, MD, MSc, FACP, FAAP, Associate Professor of Internal Medicine, Associate Professor of Pediatrics & Communicable Diseases, University of Michigan Medical School†

Steve O’Neill, BCD, JD, Clinical Instructor of Social Medicine, Faculty Associate, Center of Bioethics, Harvard Medical School*

Jody Naimark, MD, Epic Medical Director, Winchester Physician Associates; Medical Director, Beth Israel Lahey Health Performance Network†

Tom Payne, MD, Internist, UW Medicine, Professor of Medicine, University of Washington School of Medicine*

Hannah Shucard, MS, Research Coordinator, University of Washington School of Medicine*

Deb Wachenheim, MPP, Senior Project Manager, OpenNotes, Beth Israel Deaconess Medical Center†

Sarah Stephens Winnay, Co-Founder, ARCHANGELS†

Jennifer L. Wolff, PhD, Director, Roger C. Lipitz Center for Integrated Health Care, Johns Hopkins Bloomberg School of Public Health†

This investigator collaborates on OurNotes (*), and/or OurNotes for Care Partners (†).

OurNotes and OurNotes for Care Partners research partner organizations

• ARCHANGELS
• Beth Israel Deaconess Medical Center, Boston, MA
• Beth Israel Lahey Health Primary Care, Boston, MA
• Dartmouth-Hitchcock, Hanover, NH
• Michigan Medicine
• UC Health, Denver, CO
• University of Washington, Seattle, WA

Funder recognition

The Commonwealth Fund

Drane Family Fund

Ralph C. Wilson Jr. Foundation