Open Notes for All Expansion
Empowering Health Care Consumers
April 4, 2022
Clinical visit notes are an important resource for helping patients and families remember and act on information discussed during a visit, including treatment plans, medication, and care coordination.
Shared visit notes, often referred to as open notes, are an important way to help consumers become active participants in their own care. The 21st Century Cures Act, which went into effect last year, includes a federal mandate that requires all health care providers that maintain electronic medical records to make clinical notes available to patients electronically and at no charge. However, the level of compliance and, most importantly, the proactive use of open notes to improve care varies. For some hospitals, note-sharing is embedded into their practice, and they are ready to expand the types of notes and information they share and to test out innovative ways to meaningfully engage patients. For others, note-sharing is new territory, and they can benefit from adapting proven tools to their own settings and learning best practices from more experienced hospitals. In 2021, NYHealth issued a Request for Proposals (RFP), “From Good to Great: Improving Access to and Use of Patient Visit Notes,” to support hospital facilities in New York State in sharing open notes in compliance with new federal rules and in going beyond compliance to use open notes to more meaningfully engage patients. In 2022, NYHealth awarded Mount Sinai Health System (MSHS) a grant to participate in this initiative.
Under this grant, MSHS will continue to implement and improve the use of shared notes within its hospital site, promoting greater information transparency and engaging patients in their care. MSHS is an integrated health care system, comprising the Icahn School of Medicine and 8 hospital campuses across the New York metropolitan area, including more than 400 ambulatory practice locations throughout the 5 boroughs, Westchester County, and Long Island. With this grant, MSHS will educate its providers on appropriate, patient-friendly documentation, including strategies to counter bias in health care information. It will also offer training sessions for both patients and providers to improve use and understanding of visit notes. MSHS will also participate in a 12-month learning collaborative led by OpenNotes staff to explore strategies and tools for note-sharing, including understanding the new federal mandate; sustaining clinician engagement; adopting effective communication strategies to introduce open notes to both providers and patients; and sharing notes in the context of adolescent, pediatric, inpatient, and behavioral health settings, among other areas.