If anyone can testify to the power of the OpenNotes phenomenon, it is Alistair Erskine, M.D., the chief strategic information officer at the Danville, Pa.-based Geisinger Health System. Geisinger Health was one of the first hospital-based organizations in the U.S. to adopt the OpenNotes concept, as conceived by Thomas Delbanco, M.D. and Jan Walker, R.N., and implement it in their health systems (the other two being Harborview Medical Center in Seattle and Beth Israel Deaconess Medical Center in Boston). Erskine and his colleagues went live with OpenNotes in 2012.
It is in that context that HCI Editor-in-Chief Mark Hagland interviewed Dr. Erskine and other medical informaticists, healthcare leaders who are helping to change U.S. healthcare through the OpenNotes approach. OpenNotes was the subject of the July/August Healthcare Informatics cover story. To date, the OpenNotes organization estimates that 10 million patients across the U.S. have been given access to their physicians’ notes, a formidable accomplishment for a movement that is still relatively young, chronologically speaking.
Below are excerpts from Hagland’s interview earlier this summer with Dr. Erskine.
Let’s talk about Geisinger’s journey around OpenNotes so far. When did it begin, and when did you go live?
We were one of the first three health systems, along with Tom Delbanco’s group, to study this and to go live. 2012 was when we started. From the first study, three organizations. It was Harborview Medical Center [in Seattle], Beth Israel Deaconess [in Boston], and Geisinger, with primary care practices. We went live in 2012.
Alistair Erskine, M.D.
Did you coordinate with your colleagues at Beth Israel Deaconess and Harborview?
We absolutely coordinated with them, and that was really led by Tom Delbanco. He really initiated the whole thing. And each one of us wanted to find out what concerns there might be with the concept, before we went live, and what the concerns from patients and providers might be after we implemented it. And we wanted to find out how it might sustain itself over time. We went live in 2012.
What was your experience of it?
There’s a paper from the Annals of Internal Medicine on the study. It goes into the data from the three original sites. Our experience was that, before we went live, providers were more concerned than patients. Will it take longer? Will it require more messaging? Will doctors spend more time editing their notes, knowing the patient will read it? Will the doctor be more candid? How will the notes change around how we talk about cancer, or mental health, or obesity and weight loss? Will we be as efficient or more efficient? And will the notes improve patient education? Those were some of the questions we asked beforehand, and asked again after implementation. But the reality is that we’ve had virtually no complaints from either patients or providers.
And what did you find?
When it came to the number of secure e-mail communications that occurred after OpenNotes, those communications remained constant in volume; they didn’t go up. So the concern that patients would be calling clinics all the time, did not manifest, though that was a worry. And we found that the patients who initially participated, continued to participate. The idea that physicians would have to take more time addressing patients’ concerns after a visit, initially, 45 percent were worried, but afterwards, that went to 0. The concern about candid documentation went from 32 percent to 9 percent. That decreased significantly.
And the other thing that’s important about the way Geisinger approached it, differently from the other groups, is that we made it entirely voluntary. We said, if you as a group, want to share notes, there’s a mechanism to do that, and they can enroll; but if you don’t want to, we will not force you, we will not mandate that you do it. So of the 2 million visits we see at Geisinger, a portion of those—maybe 40 percent activation of our engaged patients who actually look at the record. There have been 600,000 encounters reviewed by patients out of the 2 million sets of notes released so far. So that means that the number of patients actually looking at their notes remains pretty high. In 2015, the total hits per month go from 450,000 to 50,000 per month. In other words, total hits of people looking at their notes, remains in the 50,000 range, for an annual total of 600,000. And the number of providers accounts for over 1,600 providers—physicians, PAs, residents, and fellows—the bulk are doing it. Funnily enough, the ENT doctors decided not to get involved; that was their particular culture. If you count the residents or advanced practitioners, we have just over 2,000 employed physicians. So yes, 75 percent are involved.
Have the physicians essentially said, ‘Yes, we’re glad’ you did it?
Absolutely. Virtually no complaints from either providers or patients. It’s been crickets in terms of anyone saying this is a problem, I don’t like it, please turn me back off. No one who’s gone on has decided to go back off. And per the patients, we had 277 patients who were excluded by providers for one reason or another—we had given them that option. And that’s dramatically less than 1 percent.
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