What’s Inside Your Medical Record?

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Ever wonder what your doctor writes about your office visit? Patients at UC San Diego Health can now read the medical notes signed by their primary care physician. This move toward transparency is part of an international trend to make patients feel more in control of their health care.

“UC San Diego Health is excited to participate in OpenNotes,” said Marlene Millen, MD, chief medical information officer for ambulatory care at UC San Diego Health. “Sharing medical notes with patients helps strengthen the provider-patient partnership, enhances patient safety and empowers patients to take an active role in their health and health care.”

Marlene Millen, MD, chief medical information officer for ambulatory care at UC San Diego Health

UC San Diego Health launched the OpenNotes initiative in June 2018. Participating medical teams include primary care, internal medicine, family medicine, urology, hematology and oncology. More than 30 percent of outpatients will have access to their doctor’s notes, with more clinics added over time.

“With OpenNotes, we acknowledge that patients have a right to view her or his medical records, including their physician’s notes,” said Millen. “As a primary care doctor, my hope is that these notes will help my patients have a better understanding of their overall care, and will help them see how much I think and care about them.”

Millen added that progress notes may be particularly helpful to patients with complicated medical histories to recall the details of individual visits. If a caregiver is unable to attend an appointment, the notes can be shared. The observations may also reflect the doctor’s in-depth analysis of lab and radiology results.

Sharing medical notes with patients helps strengthen the provider-patient partnership, enhances patient safety and empowers patients to take an active role in their health and health care.

Patients can access their notes through MyUCSDChart, a secure online portal that tracks medical histories, prescriptions, lab results and appointments. An email notification will be sent to patients when the notes are ready for viewing. Today, more than 22 million U.S. and Canadian patients have access to their visit notes through similar systems.

“While some may worry that OpenNotes may cause anxiety or worry among patients, published studies have shown that OpenNotes improves patient-physician communication, and can actually increase overall satisfaction,” said Christopher Longhurst, MD, chief information officer and associate chief medical officer at UC San Diego Health.

In the future, Longhurst said patients may be invited to contribute to their notes. “We are excited about helping to lead the evolution to OurNotes, when visits will be documented by both the patient and physician in a true partnership,” said Longhurst. “We have already started this process with e-check in across our entire enterprise, which invites patients to check in, complete pre-visit surveys, and update their medical information from a mobile device prior to their visit.”

Christopher Longhurst, MD, chief information officer and associate chief medical officer, UC San Diego Health

OpenNotes was launched as a pilot study by Beth Israel Deaconess Medical Center, Geisinger Health System, and Seattle’s Harborview Medical Center in 2010. More than100 primary care doctors invited 20,000 patients to read their notes via secure online portals. Among the findings: More than 77 percent of patients said open notes helped them feel more in control of their care. More than 60 percent of those taking medications reported better adherence. And 85 percent of patients said they would choose a clinician based on the availability of open notes.

To learn more about OpenNotes, visit www.opennotes.org

UC San Diego Health patients may access their notes through MyUCSDChart