Who Reads Their
PATIENTS WHO USE online portals to review their clinicians’
notes may become more actively involved in their healthcare,
but the healthcare industry knows little about factors that may
facilitate or inhibit patients’ use of this new practice. To look into
this topic, researchers from the University of Washington School
of Medicine, based in Seattle, WA, and Beth Israel Deaconess
Medical Center, Harvard Medical School, based in Boston, MA,
compared baseline perceptions about online portals between
patients who ultimately did or did not access their doctors’ primary care visit notes, using data collected through the OpenNotes initiative.
Why Conduct the Study
Millions of patients have access to their electronic health records via patient portals, with an increasing number of portals
offering access to doctors’ notes.
1 Patient access to doctors’
notes provides numerous potential benefits including better
patient-provider communication, enhanced patient satisfaction, the ability to share records with caregivers, and increased
opportunity for self-management.
2-4 Federal requirements for
the meaningful use of electronic health records also mandate
that providers offer access to online portals and incentivize organizations to encourage patient use of these portals.
Facilitating online viewing of doctors’ notes affords a unique
opportunity to educate, motivate, and engage patients.
926 million office visits in the US every year, there are ample
opportunities to engage patients via note reading.
7 However, a
multitude of these opportunities are lost because—depending
on the portal availability and implementation strategy—only
a small fraction of patients view doctors’ notes.
8 It is unclear
whether a strategy touting the benefits of online note viewing
or assuaging concerns would be more effective at encouraging
patients to use this new tool. Identifying patient perceptions
of facilitators or barriers to accessing their doctors’ notes is
important to harnessing the promise of patient engagement.
This study evaluates whether baseline differences in perceptions about viewing doctors’ notes among patients with online
portal access predict the likelihood of accessing notes.
Study Materials and Methods
OpenNotes is a national initiative that invites patients to review
the visit notes written by their doctors, nurses, or other clinicians.
The OpenNotes study methods, including survey design and vali-
dation, have been described in detail previously.
9, 10 In short, pa-
tients were given access to their primary care doctors’ visit notes
via secure, web-based patient portals for a time period of 12 to 18
months during 2010 and 2011. Patients at three geographically di-
verse locations (Beth Israel Deaconess Medical Center (BIDMC)
in Boston, MA; Geisinger Health Systems (GHS) in Danville, PA;
and Harborview Medical Center in Seattle, WA) were invited to
participate. At the time of the original study these were the only
participating sites in OpenNotes. During the intervention, pa-
tients of participating doctors were given access to their primary
care visit notes for the first time.
The baseline OpenNotes study survey, completed by patients
prior to the start of the intervention, queried patients about
demographics (age, gender, race, education, employment,
healthcare site), internet behavior (frequency of use, location of
access), and validated indicators of current health status (
self-reported health, utilization, comorbid conditions, ambulatory
care experience, perceived efficacy of interactions with doctors).
11, 12 Perceptions of the risks and benefits of viewing notes
were captured using a four-point Likert scale of agree, somewhat agree, somewhat disagree, and disagree. Of those patients
invited to participate, 9,043 ( 40 percent) completed the baseline
Two sites, BIDMC and GHS, provided data on comorbid conditions and utilization of outpatient and inpatient services
from billing records. All sites provided data indicating whether or not a patient accessed physician notes online.
Patients who completed the baseline survey and saw their
primary care doctor at least once during the study intervention period were included so that a minimum of one visit note
was available for the patient to read. For the analysis described
in this article, survey responses to perception questions were
dichotomized into agree/somewhat agree versus disagree/
somewhat disagree to account for small numbers in the extreme Likert response categories. Patients who viewed at least
one visit note during the intervention period were considered
to have accessed their clinical notes.
Differences in patient characteristics and baseline perceptions between those who did or did not access their visit notes
during the intervention period were performed using the
chi-square statistic for categorical dependent variables and
simple logistic regression for continuous variables. Multivariate models evaluated associations between patients’ baseline
perceptions and the likelihood of accessing notes. Odds ratio
estimates were adjusted for potential demographic, health,
and utilization confounders including age, sex, race, education, employment status, self-reported health, study site and a