5 OpenNotes Tips: Best Practices and Lessons Learned

by | May 12, 2021 | Articles, Practice Services

Ever since the rollout of OpenNotes – a new, federally-mandated policy requiring practitioner notes to be made more accessible to patients and proxies – medical practices and organizations across the country have been working hard to implement OpenNotes in their practice and avoid penalties for noncompliance.

Patients and healthcare professionals who have implemented this new policy are already seeing returns, with OpenNotes leading to increased patient engagement and outcomes as well as reduced liability. However, as with any new policy, there is a learning curve. Medical Advantage’s consultants have been assisting with the configuration and implementation of OpenNotes programs at organizations nationwide – read on for some of the tips, best practices, and solutions to common pitfalls they’ve discovered along the way.

Tip #1: Dispel OpenNotes Misconceptions Among Staff

It’s a common reaction, and no one can be blamed for having it: any time a new rule or regulation goes into effect, everyone is going to wonder if it will create more work. With OpenNotes, practice administration has often found staff to be hesitant about implementing the new policy, as there is a fear of it leading to an increased notetaking burden. The reality is, it won’t – in fact, OpenNotes is simply taking existing practitioner notes and making them available electronically to patients.

Another common misconception about OpenNotes is that increased patient access to practitioner notes will lead to confused – and maybe even angry – patients contacting staff with grievances about information in the notes. In practice, nearly all organizations who’ve implemented OpenNotes have found this notion to be false. In fact, most patients are more engaged, happier and healthier due to being more involved in their care.

Tip #2: Understanding Benefits Leads to Buy-In

Motivating patients, staff and administration to get on board with a new set of policies isn’t always easy. But by educating all the stakeholders involved about the positive effects OpenNotes will bring, everyone will be more willing to make the small changes necessary for success.

Talk to patients and share with them the new initiative, and how it will expand their access to their medical record. Highlight how increased access will improve their quality of care by getting them more involved – in this situation, the example of improving medication adherence can be helpful. Further, address any privacy concerns the patient may have about their data.

For staff, communicate clearly to them the new requirements, and how buying in will improve their relationships with patients as well as patient outcomes. Consider using surveys to gauge your staff’s response. For administrators and investors, explain how this will improve communication and expectations between practitioner and patient, and thereby decrease liability risks.

Tip #3: Leverage Your Patient Portal and EHR

With more and more aspects of patient engagement occurring digitally, most practices have already begun leveraging tools like their patient portal and their EHRs to improve patients’ experiences and outcomes.

Now, with OpenNotes becoming federally mandated, consider making use of these same tools to satisfy the requirements for compliance. Take advantage of your patient portal to send out notes following appointments, making them directly available to patients in their inbox. Use your EHR as your front-line tool for the new kind of notetaking you will be doing. And don’t forget to utilize other methods of technology, like email and telephone outreach, to spread awareness about OpenNotes.

Tip #4: Consider State and HIPAA Regulations – and Best Practices for Sensitive Information

Even with all of the benefits of making practitioner note information more accessible to patients and their proxies, there are some privacy considerations to be considered.

First and foremost, the ever-present HIPAA regulations concerning the use and accessibility of all patient data must be respected. Talk to administration and your IT department to make sure everyone is on the same page. Further, certain states and jurisdictions may have additional laws concerning data and privacy – be sure to take into account any of these regulations as well.

Lastly, have a plan for how you will detail certain sensitive pieces of information – for example, terminal conditions or abuse – in the notes now that patients will have increased access. In these instances, make an attempt to use language that is less technical and “people-first.” But don’t shy away from including it if you think it is important – remember that in many cases, including the information and discussing it with the patient will precipitate better patient-physician relationships, and improved outcomes.

Tip#5: Enlist Expert Help

OpenNotes implementation can be a big burden for already-stretched practice staff. Understanding the guidelines and ensuring HIPAA compliance alone can be overwhelming – not to mention the work of developing a practice plan, gaining buy-in, building and implementing new EHR workflows, developing training, creating patient engagement guides, and ensuring the program rollout goes smoothly for all stakeholders – to name just a few considerations.

One of the most powerful ways to ensure a smooth OpenNotes rollout is to enlist the help of a partner like Medical Advantage. Our experts have experience creating seamless OpenNotes implementation plans for providers of all sizes, including patient outreach, follow-up, and the ongoing support from our team should snags occur – allowing your team to remain focused on patient care and practice operations. or more information, contact one of our OpenNotes consultants today.

Speak with one of our Healthcare Experts today.

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