OHSU Grand Rounds - OpenNotes - Yackel & Woods December 2013
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The document discusses open notes, which involves sharing clinical notes with patients. It provides a history of open notes including early proposals from the 1970s and recent studies showing benefits for patients such as improved understanding, self-care, and feeling more in control of their care. The document outlines open notes experiences at institutions like the Portland VA and an open notes pilot study. Potential advantages and disadvantages of open notes are discussed. The document raises questions for discussion about whether open notes is a good idea for OHSU and next steps.
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OHSU Grand Rounds - OpenNotes - Yackel & Woods December 2013
- 1. Toward Transparency and Trust: A Conversation about OHSU and the Portland OpenNotes Collaborative Thomas Yackel, MD, MPH, MS & Susan Woods, MD, MPH
- 2. Conflict of Interest Disclosure Disclosure – Susan Woods I do not have any relationship(s) to disclose. Disclosure – Thomas Yackel I do not have any relationship(s) to disclose.
- 3. Agenda • Audience response system overview • Introduction to OpenNotes • OpenNotes: history, research, and experiences at the Portland VA • OpenNotes at OHSU • Conversation and audience response on next steps
- 4. Indicate your agreement with the statement I think sharing progress notes with patients in MyChart is a good idea A. Strongly Disagree B. Disagree C. Agree D. Strongly Agree
- 5. OpenNotes: history, research, and experiences at the Portland VA
- 6. 40 years ago, there was a “Proposal”
- 7. • Enhance patient autonomy • Improve patient-physician relationship • Serve as educational tool Shenkin B, Warner D. New England Journal Medicine 1973
- 8. Shared NHS Electronic Records 3 London practices gave record access -HealthSpace Results: 86% accessed records Age, ethnicity not associated with frequency Poorer health - more frequent access 38% found errors (48% did not take action) 76% felt more involved in care 9% more worried about health 75% felt more confident in GP (3% less confident) Bhavnani et al. Family Practice 2010; 28:188-19423
- 10. Woods SS, Schwartz E et. al. J Med Internet Res 2013;15(3):e65 10
- 11. It’s a Communication Tool “I can go in and ask more intelligent questions and we don‟t have to spend as much time with them explaining everything to me.” Woods SS, Schwartz E et. al. J Med Internet Res 2013;15(3):e65
- 12. It boosts self-care. “Made me feel more responsible for myself, like there‟s no excuses. You know, it‟s right there, you know. You can‟t use „the doctor didn‟t tell you‟.” “You could pop over to Google or the library, and see what it‟s saying instead of sitting there sweating it out trying to figure out what it is.” Woods SS, Schwartz E et. al. J Med Internet Res 2013;15(3):e65
- 13. It improves quality. “An ultrasound on my liver said….„Re-do in 6 months‟. Six months came, nothing happened. So I called the doctor. He says, „Yeah, they did say that‟. So, if I hadn‟t reminded him, I wouldn‟t have got it.” Woods SS, Schwartz E et. al. J Med Internet Res 2013;15(3):e65
- 14. It improves quality. “My Oncologist was up-front guy, he wasn‟t as up front as I thought, with what he wrote. I said to him, „I‟d like to know what you think, what you know, and what you‟re predicting. Rather than just write it in there, tell me - and then write it‟. Woods SS, Schwartz E et. al. J Med Internet Res 2013;15(3):e65
- 15. Observations on Notes & Records • Language • Errors • Inconsistencies • „Boiler plate‟ • Stress with full disclosure – But better to have it all, then none
- 17. 73 cents, Regina Holliday, Patient Advocate, Artist http://reginaholliday.blogspot.com http://www.slideshare.net/ReginaHolliday/vision-14132302#btnNext
- 19. Open Notes Study • Robert Wood Johnson Foundation Pioneer Portfolio • Beth Israel Deaconess, Harborview, Geisinger • 100 Primary Care providers and >13,000 patients • Email notification with new note upload • 2010 to 2011 (access continues) • Baseline and follow-up surveys Delbanco T, et.al. Ann Intern Med, October 2, 2012 157(7):461-470
- 20. Patient and PCP Views of Open Notes after 1 Year Takes better care of self Better understand conditions Remembers care plan better More prepared for visits More in control of care Take medications better % Agree Patients PCPs 70 28 84 41 84 44 73 36 84 49 60 31 Delbanco T, et.al. Ann Intern Med, October 2, 2012 157(7):461-470
- 21. Patient and PCP Views of Open Notes after 1 Year Felt offended % Agree Patients PCPs 2 8 More confusing than helpful 3 21 Worries more 7 42 32 -- Concerned about privacy Delbanco T, et.al. Ann Intern Med, October 2, 2012 157(7):461-470
- 23. 23
- 25. MyHealtheVet Blue Button Survey June – Sept. 2013 Preliminary data – from My HealtheVet personal health record users, on early use of Blue Button and OpenNotes…
- 26. Use of Blue Button to access notes What‟s Blue Button? Not sure I viewed notes once or more I tried to Percent 28% 27% 25% 13%
- 27. Information viewed using Blue Button Response Visit notes – primary care Visit notes – med/surg specialty Secure messaging note Visit notes – mental health Hospital visit (ER) or stay Don‟t know or remember Percent 69% 40% 34% 19% 15% 14%
- 28. WHY did you read your visit notes? Response Percent To know more about my health 25% I was curious 20% To understand what my provider said 20% To remember what was said at visit 12% Check to see if notes are right 9% To know what my provider is thinking 6%
- 29. 12% talked with health team member 12% plan to talk with health team member If YES: 53% To learn more about my health issue 34% To get an explanation on something in note 22% To discuss something I was worried about 21% To discuss something I though not correct
- 30. 74% did not/no plan to talk with health team • 82% had no reason to • 5% didn‟t want to waste their time • 5% didn‟t think it was important
- 31. Do notes correctly describe visit? 80 60 40 20 0 Pretty Well Mostly Disagree Don't Know
- 35. OpenNotes Pilot at OHSU
- 36. What does OpenNotes Look Like at OHSU for Providers?
- 37. What does Open Notes look like for patients?
- 38. What does Open Notes look like for patients?
- 39. What are other institutions doing?
- 41. Consumer Reports’ Portland Challenge
- 42. What are the advantages and disadvantages?
- 45. What would the principle advantage be? A. Improved patient understanding/participation/adherence B. Improved note completion time, accuracy, completeness C. Reduced medical errors D. Greater patient trust/appreciation E. Facilitation of pt note sharing with others
- 46. What would the principle disadvantage be? A. Patient confusion, pressure, anxiety B. Privacy problems C. Patient offended by what is written D. Unwelcome changes in documentation E. Need for additional documentation time
- 47. Indicate your agreement with the statement I think sharing progress notes with patients in MyChart is a good idea A. Strongly Disagree B. Disagree C. Agree D. Strongly Agree
- 48. Additional Discussion Questions • Is this a good idea for OHSU? • Should OHSU “sign on” to the Portland Open Notes consortium? • How should OHSU go about deciding how to implement OpenNotes? – Opt In, Opt Out, who gets to decide? • What are the next steps in this conversation?
Editor's Notes
- Of an important paper published by Shenkin and Warner, in the NEJM. 1973. The title: Giving the Patient his Medical Record: A proposal to Improve the System.The authors made a very strong argument that shared records would enhance patient autonomy, would improve the patient-clinician relationship, and the notes would serve as an educational tool. Since that time, shared records have been the exception, not the rule. But we now have a solid and growing body of research about opening notes.
- One of the first to study shared notes were practices in the UK. This paper by Bhavani in Family Practice described an observational study of 3 primary care practices in London. Every patient was given a paper copy of the note, or had access through a clinic computer and patient portal (HealthSpace).Among over 300 patients, most looked at the notes. Those will poorer health status looked more frequently. Age or ethnicity was not a factor in viewing.Just over 1/3 said that there were errors in the notes, although most did not take action.¾ of the patients felt more involved in their care – they became e-patients – AND had more confidence in their provider. Only a small minority felt more worried about their health. (that may not be a bad thing)
- Two of the most impressive Patient advocates in the US today are Regina Holliday and ePatient Dave.Regina is an awe-inspiring artist. She came into the world of ePatients through her own experience in health care. Faced with a seriously ill husband – who was dying from a malignancy – she learned how impossible it was to obtain her husband’s health information. She began telling the story and beating the drum for improvement through her art. This painting, titled 73 cents, is on an outdoor brick wall in D.C. – and portrays the excruciating tale of how the hospital told her it would cost 73 cents per page and take 21 days to get copies of his records. That’s just not meaningful use of our electronic health information.
- This is a landmark paper, published in Annals of Internal Medicine, October of this year.
- Ann Intern Med, October 2, 2012 157(7):461-470
- Planetree hospitals have been implementing open medical records since 1978
- Open Notes is being piloted at OHSU