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Patients Contributing to Their Doctors’ Notes: Insights from Expert Interviews

Patients contributing to doctors notes

Background

Doctors are increasingly allowing patients to electronically review office visit notes. Soon, patients may also be invited to enter information in their medical files using OurNotes, a new initiative to let patients, caregivers, and providers jointly create clinical notes and care plans within a shared electronic health record.

What the Study Found

Commonwealth Fund–supported researchers asked clinicians and other health care experts about the notion of patients and families contributing to their doctors’ medical notes. The interviews revealed consensus that patients would likely benefit from becoming more engaged in their care and from collaborating more closely with their clinicians. The experts most commonly endorsed asking patients to: review previous visit notes before an upcoming visit; write their medical histories since the last office visit; and identify goals for the visit.

At the same time, the experts felt that patients should be encouraged to contribute to medical notes only if doing so doesn’t increase clinicians’ workload. They also warned against pressuring those patients who are unwilling to contribute to notes.

Conclusion

Researchers are now testing OurNotes with chronically ill patients, who are invited to enter their recent medical history and identify goals for their appointments. The researchers believe that, if used effectively, medical records jointly produced by doctors and patients can improve quality of care and control costs.

Publication Details

Publication Date: December 11, 2017
Contact: Mary Mahon, Vice President, Public Information, The Commonwealth Fund
Email: mm@cmwf.org
Summary Writer: Joel T. Dodge
Citation: J. N. Mafi, M. Gerard, H. Chimowitz et al., “Patients Contributing to Their Doctors’ Notes: Insights from Expert Interviews,” Annals of Internal Medicine, published online Nov. 14, 2017.

Experts

Richard and Florence Koplow – James Tullis Professor of General Medicine and Primary Care, Harvard Medical School