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OpenNotesHomer Chin, MD, MS

Affiliate Faculty, Oregon Health Sciences UniversityFormer CMIO, Kaiser Permanente Northwest

Amy Fellows, MPHExecutive Director, We Can Do Better

2016 ORHIMA ANNUAL CONVENTION

May 12-14, 2016Portland, OR

Agenda

OpenNotes: What it is and what it isn’t

Results from a study on patient access to their providers’ notes

NW OpenNotes Consortium: A community-based approach

Key takeaways

Current status of OpenNotes

Discussion

What is OpenNotes?

“OpenNotes” is an initiative to give patient’s access to their EHR notes via the internet (using any existing EHR & patient portal)

Not a specific vendor product or software.

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2010 Study on OpenNotes

Started with a research and demonstration project in 2010, involving more than 100 PCPs and 20,000 patients in Boston (BIDMC), rural Pennsylvania (Geisinger), and the Seattle inner city (Harborview)

Patients invited to review their providers’ visit notes through secure patient portals

Each patient notified automatically via e-mail message when a note has been signed…and reminded to review it before their next scheduled visit

Supported primarily by the Robert Wood Johnson Foundation

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3 Overall Questions

Does OpenNotes help patients become more engaged in their care?

Is OpenNotes the straw that breaks the doctor’s back?

After living with this transparency, do patients and doctors want to continue?

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Among patients with notes (visits):

82% of patients opened at least one of their notes

1-8% of patients across the 3 sites reported that the notes caused confusion, worry, or offense

20-42% shared notes with others

Reports from Patients

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Reports from Patients 70-72% “taking better care of themselves” 77-85% “better understanding of their medical

conditions”

76-84% “remembering the plan for their care better”

69-80% “better prepared for visits” 77-87% “more in control of their care” 60-78% “doing better with taking my

medications as prescribed.” 85% of patients said availability of open notes would

affect their future choice of providers.

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Principal Concerns of 105 Participating PCPsImpact on workflow

Expectations(%)

Post-intervention

(%)

Visits significantly longer 24

More time addressing patient questions outside of visits

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More time writing/editing/ dictating notes

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…and, compared to the year preceding the intervention, the volume of electronic messages from patients did not change

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99% of patients wanted to continue to be able to see their visit notes online

85% of patients said availability of open notes would affect their future choice of providers

Not one doctor asked to stop

All 3 institutions decided to expand the practice widely

The bottom line

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3 Overall Questions

Does OpenNotes help patients become more engaged in their care? YES

Is OpenNotes the straw that breaks the doctor’s back? NO

After living with this transparency, do patients and doctors want to continue? YES, virtually 100%

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Patient Safety

…and 60-78% of those taking medications reported “doing better with taking my medications as prescribed

Medical adherence

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Caregivers

Mental health

The note becomes part of the treatment

[Kahn MW, Bell SK, Walker J, Delbanco T. JAMA. 2014; 311(13):1291-2]

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A New Medicine that brings

benefits… and risks

A catalyst for change…and not only

in ambulatory carePatient Safety

About the OpenNotes StudyOpenNotes

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June 2013: WCDB convenes meeting of Oregon’s health systems, consumer groups, and policy makers

September 2013: Agreement to form a consortium of health systems to collaborate together to implement OpenNotes as a community

MonthlyQuarterly: Meetings involving major health systems

NW OpenNotes Consortium

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NW Consortium Clinical Participants

Portland VA All Veterans, entire EHR since Jan 2013 (Pilot project at

Portland VA since 2001)

Kaiser NW ~1100 MDs 500K patients on April 8, 2014

OCHIN 82 member organizations in 19 states, 350 clinic

locations, over 4000 doctors Doctors can opt in, April 2014

OHSU All family practice and internal medicine patients (first

clinic in May 2014)

Portland Clinic ~105 MDs Clinic wide adoption July 2014

Vancouver Clinic ~ 220 MDs Clinic wide adoption July 2014

Early Adopters

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Right Behind PeaceHealth: 3 regions, 10 hospitals, ~800 MDs

Vancouver region live in October 2014 Rolled out to all sites in 3 regions in March 2015

Legacy Health System: 6 hospitals, ~2600 MDs All of primary care and medical specialties August 2015

Providence Oregon: 8 hospitals, 90 clinics Pilot implementation June 2015

Salem Health: 2 hospitals 1 Clinic pilot spring 2015

Reaching out to other health systems . . . Samaritan Health Services has implemented parts of

OpenNotes (radiology reports) Adventist joining the regular monthly meetings St. Alphonsus, St. Charles, Planned Parenthood,

others…21

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Adapted from Unitan, Edlund, Siedel, Kaiser Permanente Northwest, May 2, 2014

Consortium Collaboration Slide:

How To Prevent Sharing a Note

New section to allow you to hide a note if desired by you or the patient

Communicate! Communicate! Communicate!(Nobody was surprised by OpenNotes)

Internal: NWP Internal: Health Plan External

Chiefs, physicians, executives via email

and department presentations

Manager presentations, emails, huddles, FAQs,

talking points, Newswire

Press releases, brokers, direct mail, social media, AVS

SmartText

Adapted from Unitan, Edlund, Siedel, Kaiser Permanente Northwest, May 2, 2014

Consortium Collaboration Slide:

The KP Northwest journey

June 2013 - Portland Consortium

All Major Portland HealthCare Organizations

Author of Open Notes Study

Summer 2013: Presentation to Chiefs and Board of Directors

September 2013: Patient Advisory Council

November 2013: Primary Care Leadership Meeting Sentinel moment for organization

December 2013: Operational Leadership – “All In”

April 8, 2014: Big Bang – opening notes for all 7,000 outpatient visits per day

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Traffic to portal to review visit information up 400%

MD email traffic flat Rare concerns from patients about care ¼ of 1% of notes are hidden by providers Mental health providers excluded Adolescents (13-18) excluded 7,000 notes per day now available to

patients.

Kaiser Permanente Northwest:Early information on implementation

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KPNW Patient Advisory Council “Having the KP.org notification that I can view my doctor’s notes on

myself reminded me to have my labs drawn. It is a new schedule for lab draws that I had forgotten. I have a serious condition and this will help me do what my doctor wants me to do .”

“Reviewing the notes I see why I need to lose weight. I cut the notes out of KP.org and posted in my kitchen. I DO NOT WANT TO BE A DIABETIC and this is in my face. It feels like my doctor really cares about my health, I never knew that ."

“For me, the chart notes are like Paul Harvey states ' THE REST OF THE STORY "

“I told my doctor I ran every day and now I think he knows I REALLY DON'T. This may hold me more accountable to myself and my doctor“

“I wanted my doctor to treat my mind, body and spirit. I am convinced that is happening based on reading the notes.”

“The total picture of my health will help me heal”

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Outpatient (2011) Almost all labs – batch release at midnight Radiology reports, pathology reports, at 4

days, unless released earlier by physician Physician notes upon signing

Inpatient (2014) Labs – batched at midnight Radiology, pathology reports, physician notes:

Delay of 4 days unless explicitly released by physician on review

Discharge summary: upon signing; at same time all remaining reports are released

University of Iowa

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90% of outpatient providers are sharing notes (1600 providers)

Better adherence to hypertension medication

Piloting use of MyChart Bedside – iPad with access to inpatient chart. Goes home with patient for 90 days to smooth post hospital transition

Also piloting “OurNotes”

Geisinger Health System

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Susan.Wolver@vcuhealth.org

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OpenNotes: A national initiative working to give patients access to the visit notes written by their clinicians (not a specific software product)

Proven benefits: Patient engagement Minimal physician impact Cost/Benefit

Regional consortium approach Physician leadership / change management Co-opetition as a driver for adoption

Summary

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Update …

12/2015 Four Foundations announce 10 million dollar grant to OpenNotes for dissemination, innovation and research (Cambia, Moore, Peterson, & Robert Wood Johnson)

Strategic partnership with CHIME, AMDIS and other organizations (AMIA, OHLC)

Working to launch multiple consortiums Disseminating learnings and best practices Support materials available (at opennotes.org) Extending to Mental Health, Inpatient, &

OurNotes Join the movement. Become a champion for

open notes.32

General agreement that good evidence for significant benefits

Impact to physician well-being may actually be positive MD email traffic flat

?? Shorter visits ??

Better patient engagement

EHR/patient portal vendor needs to have functionality

Physician leadership and organizational change management

“Co-opetition” helps to drive pace of change Supporting and pushing/challenging each other

ONC/CMS meaningful use is an enabler for this; one of the tangible benefits of widespread EHR adoption.

Organizational Leadership is most important factor

Key Takeaways

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Thanks to:The Robert Wood Johnson Foundation

The Gordon and Betty Moore FoundationThe Peterson FoundationThe Cambia Foundation

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Changing the Culture of Medical Records, Especially Clinician Notes

Contact Information

Website: www.opennotes.org

Amy Fellows: amy@wecandobetter.org

Homer Chin: chinh@ohsu.edu

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