More hospitals and doctors are posting their notes after patient visits into the patient’s electronic health record—and more patients are reading and commenting on those notes.

But how effective patient access to those electronic notes are at improving the quality of care—or building trust between patients and doctors—remains to be seen, say medical researchers and providers.

The push for more patient access to physician notes is being led by OpenNotes, an organization launched and maintained by Harvard Medical Teaching Hospital and Beth Israel Deaconess Medical Center in Boston. OpenNotes helps various healthcare organizations establish programs that enable patients to access doctor and other provider notes through a digital healthcare portal.

Among the healthcare organizations rolling out OpenNotes are Beth Israel, Geisinger Health System in rural Pennsylvania, Harborview Medical Center in Seattle, the Veteran’s Administration in Washington, D.C., and Rush University Medical Center in Chicago.

Rush, a 664-bed academic hospital in Chicago, is now enabling patients to see all doctors notes through a secure OpenNotes web link that is a part of MyChart, Rush’s digital healthcare portal. Rush, which operates an electronic medical records system from Epic Systems Corp., piloted the new electronic medical records feature in early 2016  and rolled it out system-wide in October.

Patients already were able to see physician instructions, next steps, prescriptions and test orders online though MyChart, says Rush associate chief medical information officer Dr. Allison Weathers. But now through OpenNotes patients now can see online what their physicians have written in their medical record. Navigating health system demands and managing treatments can be difficult, particularly for individuals with complex health needs who are often under the care of multiple providers, Weathers says.

“Research shows that when patients can access their physicians’ notes, they better understand their medical issues and treatment plan as active partners in their care,” Weathers says. “Providing patients with secure web access to physician note has multiple benefits.”

OpenNotes is gaining in popularity. By 2015 more than 5 million patients at participating provider organizations had access to online physician notes through OpenNotes, a number that grew 140% to 12 million patients last year, says Dr. Homer Chin, an affiliate professor in the department of Medical Informatics and Outcomes Research at the Oregon Health and Science University and a member of the OpenNotes board of directors. Within the next several years, as the number of hospitals and health systems rolling out OpenNotes increases, as many as 50 million patients will be able to access online doctor notes through a digital health portal, Chin says.

Many studies tout the benefits of OpenNotes. “OpenNotes evidence has shown that transparent medical records can increase patient engagement and patients who read the clinical notes written by their doctors report feeling more in control of their care and being better able to adhere to the treatment plan,” says Dr. Sigall Bell, OpenNotes director of patient safety and discovery and associate professor of medicine at Harvard Medical School

New research from Beth Israel also suggests that offering patients a mechanism to provide feedback about their notes enhances engagement and can improve patient safety. In 2016 Beth Israel created an online feedback tool that patients could link to from the hospital’s digital portal to provide comments on accessing doctor notes. A total of 6,225 patient visits were included in a one-year study.

The Beth Israel survey found that nearly all (96%) of the patients who sent feedback reported understanding the content of the online physician notes. Among those who provided feedback, 23% reported potential safety concerns, most commonly citing possible mistakes regarding medications, or documentation of existing health problems or symptoms. Patients also were right most of the time. After a hospital review of the feedback, 64% of the patient-reported items were confirmed as definite or possible safety concerns, and 57% of the cases resulted in a change to the record or care, Bell says.

“The OpenNotes reporting tool helped to identify quality improvement opportunities without appearing to add to clinician burden,” Bell says. “If patients know their feedback is welcome and encouraged, the potential to reduce errors or clear up confusion about the care plan will be even greater.”

But not all healthcare providers agree that online patient access to physician notes is problem-free—or always improves the quality of care. The U.S. Veterans Administration is a big user of OpenNotes. The VA took part in the first OpenNotes pilot project in 2010 and rolled out OpenNotes system-wide in 2013. Today more than 1 million veterans now have access to physician notes through the VA’s digital portal, MyHealtheVet. But a new study of OpenNotes use by 28 veterans in Oregon with various mental and behavioral issues found that patients having online access to clinician notes came with a down side.

The VA wanted to see if OpenNotes helped—or hurt—patients’ trust in their mental health clinicians. The group the VA studied included male and female veterans of various ages, with diagnoses ranging from depression and post-traumatic stress disorder, or PTSD, to bipolar disorder and schizophrenia. Patients in the study were being treated by psychiatrists, psychologists, and other mental health therapists.

The study found that many veterans disliked “incongruity” between what happened in their sessions and what was stated in the notes. Veterans also objected to gaps in information, incorrect details, and outdated material that had been electronically copied and pasted in. Some veterans worried that errors could negatively affect their care from other providers. “Many patients said they were upset to see diagnoses that hadn’t been discussed with them,” says Dr. Steven Dobscha, director of the Center to Improve Veteran Involvement in Care, based in Portland, Ore. “This significantly eroded their trust.”

The VA intends to study more closely how veterans interact with online physician notes and develop better training for VA mental and behavioral health counselors so they can enter notes that describe in more detail feedback from the patient and the follow-up care. “We found that reading mental health notes may strengthen as well as strain patient-clinician relationships by enhancing or undermining trust,” Dubach says.