Preparing medical students and their teachers for shared medical records

Why design curricula for medical students in the open notes era?

Open notes present novel ethical and practice dilemmas. Words matter, and descriptions of social determinants of health, medical vernacular (e.g., “patient denies”) and medical terms (e.g., “obesity”) may offend patients.  Accompanied by important repercussions for trust in providers, stigmatizing language or insensitive notes may also especially affect persons from sexual/gender, cultural, ethnic, or religious minorities. Other dilemmas arise in complex family dynamics, where some individuals may expect to access their family member’s notes. 

Studies show that many clinicians report being less candid in documentation after the implementation of open notes. Upholding accuracy in clinical record-keeping remains a clear imperative. Strategies intended to avert harm, worry, or offense are understandable, yet such practices may inadvertently pose a greater risk to patients by undermining the quality of clinical documentation and true transparency. 

In this project, the educators in charge of the first two years of clinical education for Harvard Medical School students will work in close collaboration with OpenNotes to guide students and their core faculty in balancing benefits with risks of transparent communication across a range of practical dilemmas.   

Supported by a three-year grant from the Macy Foundation and a matching donation by Kate and Arnold Schmeidler, the principal goals of the project are:

• To devise a checklist of best practices for writing clinical notes addressing difficult ethical issues and the needs of diverse populations of patients. The checklist will be developed in collaboration with medical educators, OpenNotes faculty and consultants, and patients who will together create a rubric for teaching students and faculty.
• To teach medical students to compose sensitive and thoughtful notes that build trust and communicate the patient’s experience with illness, while also accurately communicating clinical data, and to develop students’ skills in talking to patients about their clinical notes. 
• To share educational material and experiences beyond Harvard Medical School with students and other health professionals nationally and internationally. With the advice of a national advisory committee of medical educators, the team will create tool kits of educational materials, videos, webinars, podcasts, case discussions, checklists, and assessments for other institutions to use and implement within their institutional curricula.

Project Team

Principal Investigator

Anita Vanka, MD, FHM, FACP
Assistant Professor of Medicine, Harvard Medical School. Course Director, Practice of Medicine course, Harvard Medical School. Associate Site Director, Core 1 Medicine Clerkship and hospitalist, Beth Israel Deaconess Medical Center

Katherine T. Johnston, MD, MA., MSc, FACP—former co-PI
Assistant Professor of Medicine, Harvard Medical School. Former Co-Director, Practice of Medicine course, Harvard Medical School. Associate Site Director, Core 1 Medicine Clerkship and primary care internist, Massachusetts General Hospital

Co-Investigators

Charlotte Blease, BSc, MA, PhD
Keane Visiting Scientist, OpenNotes, Beth Israel Deaconess Medical Center

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

Catherine M. DesRoches, DrPH
Executive Director, OpenNotes. Associate Professor of Medicine, Harvard Medical School and Beth Israel Deaconess Medical Center

Robert Stern, MD, Ed.M
Co-Leader, Macy/Schmeidler Medical Student OpenNotes Educational Initiative, Instructor of Medicine, Harvard Medical School,  Brigham and Women’s Hospital and Dana Farber Cancer Institute

Collaborators

Sigall K. Bell, MD
Director of Patient Safety and Discovery, OpenNotes, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center

Fabienne Bourgeois, MD, MPH
OpenNotes lead for Pediatrics, Assistant Professor of Pediatrics, Harvard Medical School, Pediatric hospitalist and Physician Lead of Consumer Informatics, Boston Children’s Hospital

Sara Fazio, MD, FACP
Professor of Medicine, Harvard Medical School. Advisory Dean and Director, The Walter Bradford Cannon Society, Harvard Medical School
Primary care internist, Beth Israel Deaconess Medical Center

Leonor Fernandez, MD
Assistant Professor of Medicine, Harvard Medical School. Director, Patient Engagement, Healthcare Associates
Primary care internist, Beth Israel Deaconess Medical Center

Karla Kendrick, MD
Fellow in general medicine, Harvard Medical School, Beth Israel Deaconess Medical Center

Barbara Lam, MD
Fellow in hematology and oncology, Harvard Medical School, Beth Israel Deaconess Medical Center

Daniele Olveczky, MD, MSc
Assistant Professor of Medicine, Harvard Medical School. Co-Chair, Harvard Medical School Academy Cross Cultural Interest Group. Hospitalist, Beth Israel Deaconess Medical Center

Stephen O’Neill, LICSW, BCD, JD
OpenNotes Director of Director of Behavioral Health, Faculty member, Center for Bioethics, Harvard Medical School, Former Social Work Manager for Psychiatry, Primary Care, Pain Management and Infectious Disease, Beth Israel Deaconess Medical Center

Jennifer Potter, MD
Professor of Medicine, Harvard Medical School, Advisory Dean, William B. Castle Society, Harvard Medical School, Co-Chair, the Fenway Institute, Primary care internist, Beth Israel Deaconess Medical Center

Liz Salmi
Communications & Patient Initiatives Director, OpenNotes, 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