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Moving Ahead Into OpenNotes: One Medical Specialist and Medical Informaticist Shares Her View

August 2, 2016
by Mark Hagland
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Rush University Medical Center’s Allison Weathers, M.D. shares her perspectives on OpenNotes

As the OpenNotes movement, in which physicians and patient care organizations are sharing physician notes with patients following their doctor visits, moves ahead, the medical informaticists in patient care organizations across the U.S. are figuring out ways to help lead change among their fellow physicians. That is one element that was discussed by a variety of clinical and clinical informaticist leaders across the U.S. healthcare system, with the broad spectrum of advancement in this key area the subject of the July/August Healthcare Informatics cover story.

Among the medical informaticists interviewed for that cover story was Allison Weathers, M.D., associate CMIO at Rush University Medical Center, an academic medical center in downtown Chicago. Weathers, a practicing neurologist, believes it is very important for specialists to consider how valuable opening their notes to patients can be for their practices as well—not just the practices of primary care physicians. Below are excerpts from HCI Editor-in-Chief Mark Hagland’s interview with Dr. Weathers from earlier this summer.

So much attention has been paid to the value of OpenNotes in the sphere of primary care practice. But opening physician notes to patients can prove very valuable in the specialty care practice as well, correct?

Yes, that’s right. And this is one of the areas I’m really passionate about, the power that OpenNotes has to drive patient engagement. Everyone has this vision of what old-school neurology is like, but it’s totally different now. There’s this quote that patient engagement is the blockbuster drug of the 21st century—Dr. Leonard Kish—I think it’s a great quote. So I was a huge proponent of the patient portals here at Rush. I led a lot of the education for providers. Because everybody knows how to click at this point. So what does it mean to have patients messaging you, and so forth? That was our horizon in this area.

Allison Weathers, M.D.


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And in the case of Rush University Medical Center, you were handed a bit of a timely opportunity as well, right?

Yes, that’s right. We were planning for an upgrade of our Epic EHR [electronic health record] in February of this year, anyway. It was a massive double upgrade from the version of Epic we had been on, and Epic was going to look and feel different anyway. So I said, this is a great opportunity; I have to get up in front of everybody to explain changes anyway, so why don’t we do this? So we got buy-in from hospital leadership and from the medical directors. And the bottom line is that this is the patient’s legal right to this information. Patients could get off a call and call health information management and get their legal record, anyway.

So what we chose to do was, for every next ambulatory visit from go-live, from February 8 on, all ambulatory notes as a default, were going to be released. However, at the individual note level, you always have the option to opt out. It’s a big blue box at the top of your screen. So if it’s going to be unduly upsetting or otherwise problematic, you can always choose to unshare the note. The data for mental health providers isn’t quite as strong yet, so for our psychologists and psychiatrists, their box is by default unchecked. So they have to go in and manually unclick it.

You’ve been in your position since January 2013, and have been working closely with Brian Patty, M.D., your organization’s CMIO, on all this, correct? And you’re also still practicing clinically part-time?

Yes, that’s correct. I always joke that Brian is kind of the vision and strategy guy, and I’m kind of the person in the weeds, working with the physicians. So it’s important for me to continue to practice, for that position. I’m an academic general neurologist; and I’m spending half of my time in clinical practice and half of my time in medical informatics.

It seems obvious to me that we need more specialists who are functioning as medical informaticists in patient care organizations, for so many reasons.

Yes. And it’s interesting, a lot of medical informaticists do come up through ED or primary care. But yes, it’s nice that I’ve been able to do that. Initially when I got involved, there weren’t that many neurologists who were involved. So I’ve gotten really involved with Epic, and I’m helping them to make their build better for neurologists, and with the American Academy of Neurology.

How many years have you been involved in informatics in some way?

I really began when I was still a fellow. The CMIO of Rush at the time needed someone to be a liaison to house staff, so I essentially became that liaison to our house staff, back in 2007.

Do you have any metrics yet on some of this advancement?

As of [April], over 83,000 notes had been shared. However, only about 33,000 of those notes were for MyChart-active patients. And only about 185 have actually been viewed, because we did this as a soft rollout. We said, we’re going to keep this quiet at the beginning, to make sure the doctors weren’t coming at me with pitchforks. Because the fear is that patients will call when the grammar is wrong or they don’t understand a word. But the studies have shown that that’s not true, they go to Google for that.

And we recently went back to the heads of the medical practices with request for feedback. They told us that everything was turning out just fine. In fact, we’ve heard very little negative feedback. Instead, what we got for the heads of the practices was basically a bunch of shrugs. Meanwhile, this can be so meaningful for patients. So I said, “game on.” And I went back to our marketing department, and said, “Look at this cool thing” [the soft rollout of OpenNotes]. So Marketing is preparing a story about this, to be published soon in our patient-facing publication. And to my knowledge, we are the only hospital in Illinois that has so far done this.

Altogether, how many physicians are involved in this so far?

It’s a couple of hundred. Right now it’s our Rush University Medical Group, and plus some of our affiliated practices, such as Rush Oak Park Physicians Group, as well as a few scattered other providers.

When might this initiative move into the inpatient sphere?

I’m aware that there are some pilot sites around the country that are experimenting with this on an inpatient basis, but it’s not as widespread yet in inpatient. There are issues with copying and pasting. That’s much more of an issue on the inpatient side; there are more limitations. I’d love to get there, and some hospitals starting to move closer to that reality.

What’s your assessment of the OpenNotes movement so far?

I think it’s working very well. And with regard to workflow and related issues, it’s turned out to be a non-issue among providers [physicians]. It’s not creating more work for us, we haven’t gotten more phone calls. I had a conversation with a patient the other day; I was giving her complicated instructions, and I told her about this, and she said, oh, that’s really great. She’s a very intelligent woman, she was about to go into surgery. And it was really an amazing thing for her to go back and have that as a reference.

And if you look at some of the quotes that have come out per these studies, even patients feel it helps to hold them accountable. It’s a partnership. At the end of the day, it has to make sense for them. But sometimes, being able to go back after the fact and read why I made a recommendation, sometimes that helps the patients. And two, it holds them accountable. Like when the patient says, oh yeah, my doctor told me to quit smoking. When they see it written, it holds a different weight.

Were some of the specialists at Rush perhaps a little bit more frightened than some of the PCPs?

Yes, I think there was some concern. But we decided to try to allay those concerns as much as possible. And that was my other thing: for a hospital that touts who innovative we are, how much we’re on the cutting edge. And other hospitals have been doing this for five years now. And how do we say we’re on the cutting edge if we’re not even making information available to patients, that’s their legal right?

And I’m working on a project with the American Academy of Neurology, we’re putting together a toolkit for neurologists on this topic. What are the things to look out for? And a lot of times, patients come in with symptoms, we don’t yet have a diagnosis. Or sometimes, with a diagnosis, we’re not finding a physiologic cause and we might feel that stress might play a role, and how do we get that out there? And I’m working with two other neurologists as well as the CMO, another neurologist, of a neurology practice, as well. Two doctors are in Texas, and one in California, and me.

When will your toolkit be ready?

Hopefully, the basic toolkit will be out soon. The paper, we’re hoping to have that submitted in the next few months.

What have been your and your colleagues’ biggest lessons learned around all this so far, and what would your advice to CMIOs and CIOs be, based on that?

I’m going to steal the quotes of the teams who went before us. There’s a lot of angst, a lot of fear, over what turns out to be the biggest non-issue for providers. So you just need to get in there. I try to work very closely in partnership with providers. At some point, though, we know this is the right thing to do. And you’ve got to move forward. And we could still be focus-group-ing and committee-ing around this. And that can be important, but we just had to move forward with it. It’s the right thing to do for patients.

I think one key element in our case was that I went in prepared when I presented on this opportunity. I had my data, I had my PowerPoint; and I had support from other clinician leaders. I had one of our vice-presidents, a physician leader over the medical group, and other support. It wasn’t like IT was driving this one.

And that’s important, too, correct?

Yes, that’s critical that it not be an IT thing. If I hadn’t gotten his support, I couldn’t do it. And I had the support of the physician leader at Rush Oak Park as well.


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Allscripts Sells its Netsmart Stake to GI Partners, TA Associates

December 10, 2018
by Rajiv Leventhal, Managing Editor
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Just a few months after Allscripts said it would be selling its majority stake in Netsmart, the health IT company announced today that private equity firm GI Partners, along with TA Associates, will be acquiring the stake held in Netsmart.

In 2016 Allscripts acquired Kansas City-based Netsmart for $950 million in a joint venture with middle-market private equity firm GI Partners, with Allscripts controlling 51 percent of the company. With that deal, Allscripts contributed its homecare business to Netsmart, in exchange for the largest ownership stake in the company which has now become the largest technology company exclusively dedicated to behavioral health, human services and post-acute care, officials have noted.

Now, this transaction represents an additional investment for GI Partners over its initial stake acquired in April 2016, and results in majority ownership of Netsmart by GI Partners.

According to reports, it is expected that this sale transaction will yield Allscripts net after-tax proceeds of approximately $525 million or approximately $3 per fully diluted share.

Founded 50 years ago, Netsmart is a provider of software and technology solutions designed especially for the health and human services and post-acute sectors, enabling mission-critical clinical and business processes including electronic health records (EHRs), population health, billing, analytics and health information exchange, its officials say.

According to the company’s executives, “Since GI Partners' investment in 2016, Netsmart has experienced considerable growth through product innovation and multiple strategic acquisitions. During this time, Netsmart launched myUnity, [a] multi-tenant SaaS platform serving the entire post-acute care continuum, and successfully completed strategic acquisitions in human services and post-acute care technology. Over the same period, Netsmart has added 150,000 users and over 5,000 organizations to its platform.”

On the 2018 Healthcare Informatics 100, a list of the top 100 health IT vendors in the U.S. by revenue, Allscripts ranked 10th with a self-reported health IT revenue of $1.8 billion. Netsmart, meanwhile, ranked 44th with a self-reported revenue of $319 million.

According to reports, Allscripts plans to use the net after-tax proceeds to repay long-term debt, invest in other growing areas of its business, and to opportunistically repurchase its outstanding common stock.

The transaction is expected to be completed this month.

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Study Links Stress from Using EHRs to Physician Burnout

December 7, 2018
by Heather Landi, Associate Editor
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More than a third of primary care physicians reported all three measures of EHR-related stress
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Physician burnout continues to be a significant issue in the healthcare and healthcare IT industries, and at the same time, electronic health records (EHRs) are consistently cited as a top burnout factor for physicians.

A commonly referenced study published in the Annals of Internal Medicine in 2016 found that for every hour physicians provide direct clinical face time to patients, nearly two additional hours are spent on EHR and desk work within the clinic day.

Findings from a new study published this week in the Journal of the American Medical Informatics Association indicates that stress from using EHRs is associated with burnout, particularly for primary care doctors, such as pediatricians, family medicine physicians and general internists.

Common causes of EHR-related stress include too little time for documentation, time spent at home managing records and EHR user interfaces that are not intuitive to the physicians who use them, according to the study, based on responses from 4,200 practicing physicians.

“You don't want your doctor to be burned out or frustrated by the technology that stands between you and them,” Rebekah Gardner, M.D., an associate professor of medicine at Brown University's Warren Alpert Medical School, and lead author of the study, said in a statement. “In this paper, we show that EHR stress is associated with burnout, even after controlling for a lot of different demographic and practice characteristics. Quantitatively, physicians who have identified these stressors are more likely to be burned out than physicians who haven't."

The Rhode Island Department of Health surveys practicing physicians in Rhode Island every two years about how they use health information technology, as part of a legislative mandate to publicly report health care quality data. In 2017, the research team included questions about health information technology-related stress and specifically EHR-related stress.

Of the almost 4,200 practicing physicians in the state, 43 percent responded, and the respondents were representative of the overall population. Almost all of the doctors used EHRs (91 percent) and of these, 70 percent reported at least one measure of EHR-related stress.

Measures included agreeing that EHRs add to the frustration of their day, spending moderate to excessive amounts of time on EHRs while they were at home and reporting insufficient time for documentation while at work.

Many prior studies have looked into the factors that contribute to burnout in health care, Gardner said. Besides health information technology, these factors include chaotic work environments, productivity pressures, lack of autonomy and a misalignment between the doctors' values and the values they perceive the leaders of their organizations hold.

Prior research has shown that patients of burned-out physicians experience more errors and unnecessary tests, said Gardner, who also is a senior medical scientist at Healthcentric Advisors.

In this latest study, researchers found that doctors with insufficient time for documentation while at work had 2.8 times the odds of burnout symptoms compared to doctors without that pressure. The other two measures had roughly twice the odds of burnout symptoms.

The researchers also found that EHR-related stress is dependent on the physician's specialty.

More than a third of primary care physicians reported all three measures of EHR-related stress -- including general internists (39.5 percent), family medicine physicians (37 percent) and pediatricians (33.6 percent). Many dermatologists (36.4 percent) also reported all three measures of EHR-related stress.

On the other hand, less than 10 percent of anesthesiologists, radiologists and hospital medicine specialists reported all three measures of EHR-related stress.

While family medicine physicians (35.7 percent) and dermatologists (34.6 percent) reported the highest levels of burnout, in keeping with their high levels of EHR-related stress, hospital medicine specialists came in third at 30.8 percent. Gardner suspects that other factors, such as a chaotic work environment, contribute to their rates of burnout.

"To me, it's a signal to health care organizations that if they're going to 'fix' burnout, one solution is not going to work for all physicians in their organization," Gardner said. "They need to look at the physicians by specialty and make sure that if they are looking for a technology-related solution, then that's really the problem in their group."

However, for those doctors who do have a lot of EHR-related stress, health care administrators could work to streamline the documentation expectations or adopt policies where work-related email and EHR access is discouraged during vacation, Gardner said.

Making the user interface for EHRs more intuitive could address some stress, Gardner noted; however, when the research team analyzed the results by the three most common EHR systems in the state, none of them were associated with increased burnout.

Earlier research found that using medical scribes was associated with lower rates of burnout, but this study did not confirm that association. In the paper, the study authors suggest that perhaps medical scribes address the burden of documentation, but not other time-consuming EHR tasks such as inbox management.


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HHS Studying Modernization of Indian Health Services’ IT Platform

November 29, 2018
by David Raths, Contributing Editor
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Options include updating the Resource and Patient Management System technology stack or acquiring commercial solutions

With so much focus on the modernization of health IT systems at the Veteran’s Administration and Department of Defense, there has been less attention paid to decisions that have to be made about IT systems in the Indian Health Service. But now the HHS Office of the Chief Technology Officer has funded a one-year project to study IHS’ options.

The study will explore options for modernizing IHS’ solutions, either by updating the Resource and Patient Management System (RPMS) technology stack, acquiring commercial off-the-shelf (COTS) solutions, or a combination of the two. One of the people involved in the analysis is Theresa Cullen, M.D., M.S., associate director of global health informatics at the Regenstrief Institute. Perhaps no one has more experience or a better perspective on RPMS than Dr. Cullen, who served as the CIO for Indian Health Service and as the Chief Medical Information Officer for the Veterans Health Administration

During a webinar put on by the Open Source Electronic Health Record Alliance (OSEHERA), Dr. Cullen described the scope of the project. “The goal is to look at the current state of RPMS EHR and other components with an eye to modernization. Can it be modernized to meet the near term and future needs of communities served by IHS? We are engaged with tribally operated and urban sites. Whatever decisions or recommendations are made will include their voice.”

The size and complexity of the IHS highlights the importance of the technology decision. It provides direct and purchased care to American Indian and Alaska Native people (2.2 million lives) from 573 federally recognized tribes in 37 states. Its budget was $5.5 billion for fiscal 2018 appropriations, plus third-party collections of $1.02 billion at IHS sites in fiscal 2017. The IHS also faces considerable cost constraints, Dr. Cullen noted, adding that by comparison that the VA’s population is four times greater but its budget is 15 times greater.

RPMS, created in 1984, is in use at all of IHS’ federally operated facilities, as well as most tribally operated and urban Indian health programs. It has more than 100 components, including clinical, practice management and administrative applications.


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About 20 to 30 percent of RPMS code originates in the VA’s VistA. Many VA applications (Laboratory, Pharmacy) have been extensively modified to meet IHS requirements. But Dr. Cullen mentioned that IHS has developed numerous applications independently of VA to address IHS-specific mission and business needs (child health, public/population health, revenue cycle).

Because the VA announced in 2017 it would sundown VistA and transition to Cerner, the assessment team is working under the assumption that the IHS has only about 10 years to figure out what it will do about the parts of RPMS that still derive from VistA. And RPMS, like VistA, resides in an architecture that is growing outdated.

The committee is setting up a community of practice to allow stakeholders to share technology needs, best practices and ways forward. One question is how to define modernization and how IHS can get there. The idea is to assess the potential for the existing capabilities developed for the needs of Indian country over the past few decades to be brought into a modern technology architecture. The technology assessment limited to RPMS, Dr. Cullen noted. “We are not looking at COTS [commercial off the shelf] products or open source. We are assessing the potential for existing capabilities to be brought into “a modern technology architecture.”

Part of the webinar involved asking attendees for their ideas for what a modernized technology stack for RPMS would look like, what development and transitional challenges could be expected, and any comparable efforts that could inform the work of the technical assessment team.




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