Determining implementation issues of open notes in primary care: a focus group study

Abstract Background In several countries, patients have online access to medical records (open notes) contributing to patient engagement and healthcare outcomes. However, usage is still low. Healthcare professionals’ viewpoints on open notes are under-represented in existing reviews. And a systemati...

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Main Authors: Marianne Dees, Sevde Alkir-Yurt, Gert Olthuis, Jozé Braspenning
Format: Article
Language:English
Published: BMC 2025-04-01
Series:BMC Primary Care
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Online Access:https://doi.org/10.1186/s12875-025-02805-1
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author Marianne Dees
Sevde Alkir-Yurt
Gert Olthuis
Jozé Braspenning
author_facet Marianne Dees
Sevde Alkir-Yurt
Gert Olthuis
Jozé Braspenning
author_sort Marianne Dees
collection DOAJ
description Abstract Background In several countries, patients have online access to medical records (open notes) contributing to patient engagement and healthcare outcomes. However, usage is still low. Healthcare professionals’ viewpoints on open notes are under-represented in existing reviews. And a systematic framework to understand the implementation is lacking. Using the ‘capability approach’, we evaluated the value of open notes by examining influencing factors and capabilities (opportunities and challenges) of patients and staff in general practices. Method Qualitative research was conducted in 10 Dutch general practices (19 healthcare professionals and 29 patients) that were included through purposive sampling aiming at a diversity of practices and patients. Three focus groups were held with primary care staff and 10 with patients, led by an experienced facilitator using a topic guide. Content analysis was used for the transcripts of the focus groups; coded in ATLAS.ti in three rounds by two researchers independently. The results were discussed with the research team to identify factors and capabilities that could affect the usability of open notes. Results Personal, social, and environmental factors appeared to influence the use of open notes, such as digital and health literacy, social support from and within the practice, and legislation and regulation. Patients and healthcare professionals agreed on most of these factors. From the capabilities, four implementation themes were identified. First, ambiguity about ownership of medical records and concerns about data integrity should be addressed. Second, the change in practice organization and the care process caused by open notes need practical support. Third, fear of the unknown and unintended consequences of open notes must be considered. Fourth, the introduced change to the healthcare professional-patient relationship requires additional skills. These themes applied to both patients and healthcare professionals, but the differences became clear in the details. Conclusion The study provides insight into how patients and healthcare professionals experience open notes. Besides the practical barriers and facilitators, patients and healthcare professionals addressed four implementation themes that should guide the further implementation of open notes to improve patient engagement and health outcomes.
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spelling doaj-art-e2f32f987c1342b8b119ecb05f6c2a142025-08-20T02:30:18ZengBMCBMC Primary Care2731-45532025-04-0126111010.1186/s12875-025-02805-1Determining implementation issues of open notes in primary care: a focus group studyMarianne Dees0Sevde Alkir-Yurt1Gert Olthuis2Jozé Braspenning3Radboud University Medical Centre, Radboud Institute for Health Sciences, IQ healthcareRadboud University Medical Centre, Radboud Institute for Health Sciences, IQ healthcareRadboud University Medical Centre, Radboud Institute for Health Sciences, IQ healthcareRadboud University Medical Centre, Radboud Institute for Health Sciences, IQ healthcareAbstract Background In several countries, patients have online access to medical records (open notes) contributing to patient engagement and healthcare outcomes. However, usage is still low. Healthcare professionals’ viewpoints on open notes are under-represented in existing reviews. And a systematic framework to understand the implementation is lacking. Using the ‘capability approach’, we evaluated the value of open notes by examining influencing factors and capabilities (opportunities and challenges) of patients and staff in general practices. Method Qualitative research was conducted in 10 Dutch general practices (19 healthcare professionals and 29 patients) that were included through purposive sampling aiming at a diversity of practices and patients. Three focus groups were held with primary care staff and 10 with patients, led by an experienced facilitator using a topic guide. Content analysis was used for the transcripts of the focus groups; coded in ATLAS.ti in three rounds by two researchers independently. The results were discussed with the research team to identify factors and capabilities that could affect the usability of open notes. Results Personal, social, and environmental factors appeared to influence the use of open notes, such as digital and health literacy, social support from and within the practice, and legislation and regulation. Patients and healthcare professionals agreed on most of these factors. From the capabilities, four implementation themes were identified. First, ambiguity about ownership of medical records and concerns about data integrity should be addressed. Second, the change in practice organization and the care process caused by open notes need practical support. Third, fear of the unknown and unintended consequences of open notes must be considered. Fourth, the introduced change to the healthcare professional-patient relationship requires additional skills. These themes applied to both patients and healthcare professionals, but the differences became clear in the details. Conclusion The study provides insight into how patients and healthcare professionals experience open notes. Besides the practical barriers and facilitators, patients and healthcare professionals addressed four implementation themes that should guide the further implementation of open notes to improve patient engagement and health outcomes.https://doi.org/10.1186/s12875-025-02805-1Primary careOpen notesPatient engagementImplementationCapability approachFocus group
spellingShingle Marianne Dees
Sevde Alkir-Yurt
Gert Olthuis
Jozé Braspenning
Determining implementation issues of open notes in primary care: a focus group study
BMC Primary Care
Primary care
Open notes
Patient engagement
Implementation
Capability approach
Focus group
title Determining implementation issues of open notes in primary care: a focus group study
title_full Determining implementation issues of open notes in primary care: a focus group study
title_fullStr Determining implementation issues of open notes in primary care: a focus group study
title_full_unstemmed Determining implementation issues of open notes in primary care: a focus group study
title_short Determining implementation issues of open notes in primary care: a focus group study
title_sort determining implementation issues of open notes in primary care a focus group study
topic Primary care
Open notes
Patient engagement
Implementation
Capability approach
Focus group
url https://doi.org/10.1186/s12875-025-02805-1
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AT jozebraspenning determiningimplementationissuesofopennotesinprimarycareafocusgroupstudy