12 Strategies for Success With Open Notes in Healthcare: The Cures Act

Chad Anguilm, MBA; Richard F. Cahill, JD; and Kathleen Stillwell, MPA/HSA, RN

A decade ago, a pilot project allowed patients electronic access to most kinds of medical notes in a test of “open notes.” The participating physicians dreaded an increase in both administrative workloads and phone calls from angry patients. Yet the things physicians were dreading never materialized—and in fact, the outcomes were surprisingly positive: Patients overwhelmingly reported feeling more in control of their own care, while few of the participating physicians reported spending additional time on patient education. Tellingly, none of the physicians who participated in the pilot project returned to closed notes.

On April 5, 2021, the 21st Century Cures Act prohibition on information blocking, also known as the requirement for open notes, went into effect. All providers who use electronic health records (EHRs) must comply, and patients must be able to access information in their EHRs “without delay.” While patient access to medical notes is not new, the scale on which open notes is being implemented is new—and physicians may feel that they are involuntarily participating in a nationwide version of that old pilot project. They may have the same fears regarding increased administrative burdens and damaged patient relationships. Open notes optimists are predicting that those fears will once again be allayed by a better-than-expected experience.

Writing open notes does come with a learning curve, but overall, many providers find that after a few months of practice, their notes become much more comprehensible to lay readers.

12 Strategies for a Smooth Transition to Open Notes

When composing notes, certain strategies raise the odds that notes will be well understood and well received. Beyond being clear and succinct, strategies for success include:

  1. Invite patients to participate in the note-writing process: During the visit, ask patients to read their notes, and check for understanding and accuracy. Encourage patients to refer to notes: “Reading your notes may remind you of what we discussed. You can share it with family members or caregivers if you like.”
  2. Consider beginning your note with the Assessment and Plan section. Many EHR systems allow your locking style to change based on your needs, i.e., you document in a typical subjective, objective, assessment, and plan (SOAP) format, but once locked, the assessment and plan are front and center. Include only pertinent aspects of current visits, and avoid importing multiple pages of data available elsewhere in the EHR.
  3. Consider composing at least a portion of the note as instructions addressed directly to the patient. More direct language may help reinforce instructions for patients. For example: “Start taking lisinopril and check your blood pressure twice a week,” vs. “Initiated lisinopril and instructed her to check her blood pressure twice a week.”
  4. When possible, use boldface text or other visual emphasis to call out important items such as check your blood sugar twice a day.”
  5. Avoid jargon. Patients don’t expect layperson’s terminology, but they need to be able to follow the note.
  6. Make technology work for you. Use electronic tools to convert abbreviations to full spelling. Create templated versions of explanations that you frequently provide.
  7. If you must use some shortened terms, take care to avoid those that might be particularly offensive if misconstrued. For example, a physician might use the accepted abbreviation for “follow up regarding shortness of breath,” “which could easily be misunderstood by a patient.
  8. Caution patients about the potential for misunderstandings, and/or include templated statements and offer a list of common medical abbreviations. Another solution is inserting links to reliable online resources for clarification regarding medical terms.
  9. Directly and respectfully address concerns. For example, for patients with obesity, review body mass index to clarify that emotionally fraught terms like overweight, obese, and morbidly obese are clinical terms, and not subjective judgments imposed by the physician.
  10. Use supportive, nonjudgmental language. For example: “Patient lost five pounds and is motivated to continue positive trend toward goal of 20 pounds” vs. “Patient still needs to lose another 15 pounds.” Another example would be: “Patient chose not to pursue treatment” vs. “Patient refused treatment.”
  11. Avoid subjective comments regarding the patient’s appearance or manner.
  12. Plan ahead for 2023:
  1. Staff task notes will also become accessible to patients. Start training practice staff to keep any subjective comments out of written communication.
  2. Interoperability requirements for EHRs will include mobile devices like cell phones or the Apple Watch.

To learn more about what’s next for open notes, see Open Notes: Healthcare Providers Should Prepare Now for 2023 and the Cures Act.

Chad Anguilm, MBA, is Vice President, In-Practice Technology Services, Medical Advantage, part of TDC Group. Richard F. Cahill, JD, is Vice President and Associate General Counsel, The Doctors Company, part of TDC Group. Kathleen Stillwell, MPA/HSA, RN, is Senior Patient Safety Risk Manager, The Doctors Company, part of TDC Group.

The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider considering the circumstances of the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.