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Open Notes: New Federal Rules Promoting Open and Transparent Communication

Published:February 12, 2021DOI:https://doi.org/10.1016/j.jcjq.2021.02.004
      While health systems and clinicians are increasingly aware of new federal rules

      OpenNotes. Federal Rules Mandating Open Notes. opennotes.org. Published 2021. https://www.opennotes.org/onc-federal-rule/.

      that mandate offering patients access to the notes clinicians write in electronic health records (open notes), for many, and certainly for patients and their families, they come as a surprise. Taking effect April 5, 2021, the rules enact the bipartisan 21st Century Cures Act and aim to increase interoperability and ensure greater transparency in health care. Many health professionals support these goals but are anxious about how their practice and clinician-patient relationships may be affected. Stimulated in part by the OpenNotes movement,

      OpenNotes. OpenNotes Homepage. OpenNotes. Published 2020. Accessed 26 November 2019. https://www.opennotes.org/.

      considerable anecdotal and research evidence is accumulating from the more than 250 health systems

      OpenNotes. OpenNotes Map. Accessed 25 May 2020. https://www.opennotes.org/join/map/.

      already sharing clinical notes with 55 million Americans registered on their electronic patient portals. More than 100 papers have been published dissecting the effects on care of this fundamental change in practice.

      OpenNotes. OpenNotes Homepage. OpenNotes. Published 2020. Accessed 26 November 2019. https://www.opennotes.org/.

      What is being learned?
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      REFERENCES

      1. OpenNotes. Federal Rules Mandating Open Notes. opennotes.org. Published 2021. https://www.opennotes.org/onc-federal-rule/.

      2. OpenNotes. OpenNotes Homepage. OpenNotes. Published 2020. Accessed 26 November 2019. https://www.opennotes.org/.

      3. OpenNotes. OpenNotes Map. Accessed 25 May 2020. https://www.opennotes.org/join/map/.

        • Walker J
        • et al.
        OpenNotes after 7 years: Patient experiences with ongoing access to their clinicians’ outpatient visit notes.
        J Med Internet Res. 2019; 21: e13876
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        Patients managing medications and reading their visit notes: A survey of OpenNotes participants.
        Ann Intern Med. 2019; 171: 69-71
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        • et al.
        Sharing physician notes through an electronic portal is associated with improved medication adherence: Quasi-experimental study.
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        Patients evaluate visit notes written by their clinicians: A mixed methods investigation.
        J Gen Intern Med. Epub. 2020 July 15;
      4. Klein JW, et al. Suggestions for implementing Open Notes in clinical practice. 2016. https://www.opennotes.org/wp-content/uploads/2016/02/Klein_notes-tip_toolkit.pdf.

        • Klein JW
        • et al.
        Your patient is now reading your note: Opportunities, problems, and prospects.
        Am J Med. 2016; 129: 1018-1021
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      5. OpenNotes. Webinars. opennotes.org. Published 2021. https://www.opennotes.org/webinars/.

      6. OpenNotes. The Research Continues. opennotes.org. Published 2021. https://www.opennotes.org/research/.