Open Notes: An Overview at the Pivotal Trial (and Thinking About My Notes)

Open notes is the process of providing online access to patients so they can read the notes created by their providers.

The goal of sharing notes with patient is to deepen the patient's understanding of their illness and create a more accurate patient electronic health record. The hope is that patients who read their notes become more activated in their care which may lead to better health outcomes.

In this post, I offer the busy clinician a high-level overview of the pivotal trial published by Delbanco and colleagues and published in 2012 in the Annals of Internal Medicine (visual summary below). I also share my perspective on this topic and list a few key references.

The lead authors of this paper, Tom Delbanco, MD, & Jan Walker, RN, MBA, have cofounded OpenNotes™ which is an excellent starting point to understand the open notes movement.


The Pivotal Trial on Open Notes



How I Hope My Patients Will Read My Open Notes

The OpenNotes movement is expanding rapidly in health care.

I am embracing positively the idea of having patients read their notes for my visit.

For me, a note should capture the patient's story and reflect how illness impacts his or her life. Summarizing key diagnostic and therapeutic data is something we all strive to include in a good note.

If a patient reads my note, my hope is they will see the following:

  • a story, snippets of events that show the life they live and how illness impacts them
  • a list of test results, treatment tried
  • a plan of action they can follow, reinforcing what we discussed in clinic
  • the importance of adhering to treatment

The hard part in today's EHR is removing information that can sometimes clutter and choke a note and overwhelm the reader.  That is a topic for another day.

I don't plan on eliminating the technical language of my profession so that a patient can understand all that I say. It is important for me to preserve the precision of describing my findings and my clinical reasoning using the technical language that is needed for my colleagues and I.

I will continue to discuss sensitive topics in gastroenterology/hepatology like substance dependence, psychiatric history, sexual professionally and with sensitivity. My hope is the patient will not feel uncomfortable reading about these topics.

The initial experience from the pivotal study completed by Delbanco and reported in the Annals of Internal Medicine, 2012, suggests an overall positive experience for patient and doctor. The limitations of the study include the intervention of the open notes trial to PCP's and the absence of house officers. A minority of patients felt uncomfortable with what was written.

Writing a thoughtful note always takes skill and practice. As clinician-educators in Medicine, we have to help trainees be mindful of how they write notes by modeling good note writing for them.

Selected References

1. Bell, S. K. et al. When doctors share visit notes with patients: a study of patient and doctor perceptions of documentation errors, safety opportunities and the patient–doctor relationship. BMJ Qual Saf 26, 262–270 (2017).

2. Root, J. et al. Characteristics of Patients Who Report Confusion After Reading Their Primary Care Clinic Notes Online. Health Commun 31, 778–781 (2016).

3. Walker, J., Meltsner, M. & Delbanco, T. US experience with doctors and patients sharing clinical notes. BMJ 350, g7785–g7785 (2015).

4. Greene, J., Hibbard, J. H., Sacks, R. & Overton, V. When seeing the same physician, highly activated patients have better care experiences than less activated patients. Health Aff (Millwood) 32, 1299–1305 (2013).

5. Delbanco, T. et al. Inviting patients to read their doctors' notes: a quasi-experimental study and a look ahead. Ann Intern Med 157, 461–470 (2012).

6. Leveille, S. G. et al. Evaluating the impact of patients‘ online access to doctors’ visit notes: designing and executing the OpenNotes project. BMC Med Inform Decis Mak 12, 32 (2012).

7. Walker, J. et al. Inviting Patients to Read Their Doctors' Notes: Patients and Doctors Look AheadPatient and Physician Surveys. Ann Intern Med 155, 811–819 (2011).

8. Delbanco, T. et al. Open Notes: Doctors and Patients Signing On. Ann Intern Med 153, 121–125 (2010).



  1. OpenNotes™ an excellent starting point to understand the open notes movement.
  2. Robert Wood Johnson Foundation, a supporter of the open notes pivotal trial


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Created and maintained by Raf Rizk, MD | Division of Gastroenterology | Michigan Medicine

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