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Geisinger’s Chief Strategic Information Officer: OpenNotes Is the Future

August 8, 2016
by Mark Hagland
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Alistair Erskine, M.D. sees OpenNotes as a key element in the new patient-physician relationship

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.


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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.

What about the concerns that it would take more time or force physicians and providers to dramatically alter their documentation?

As far as taking more time, that didn’t happen at all. As far as certain sensitive topics, meaning cancer, substance abuse, mental health and obesity, with obesity, the concern went from 18 percent to 5 percent, around obesity.

After four years’ experience, what have been the biggest learnings for you and your colleagues around this? And what would you especially want for CMIOs to know?

The first thing for other CMIOs to do is to start with the vision that there is a national movement to be more transparent in healthcare, and to share what we’re doing in our ‘secret little medical records,’ with the patients. And share with the physicians the papers that document that these concerns don’t play out. And share that the vendors are making this easier to do. For example, Epic in their 2015 version, will make it that the default will be sharing with patients, and you have to check not sharing. So vendors are adding features and functions to support the OpenNotes movement.

Now, there is a laundry list of decisions around configuration. First, do your patients have access to a portal? Because if your patients don’t have access to a portal, they won’t be able to see the notes. So the CMIO needs to know the rate of patient portal adoption in their system. If for example they don’t have a portal or the rate of adoption is 5 percent, they could do OpenNotes all day long, but only 5 percent of patients would see the notes. Second, they need to decide whether this should be mandatory or voluntary.

Third, they need to decide on outpatient, emergency department, inpatient, notes. Fourth, are they going to allow residents to share notes, or only attendings? Fifth, are any notes going to be excluded? Does the psychiatrist or psychologist share notes? And do we turn off certain kinds of notes, so that psychotherapy notes are never shared, for example? And does a note get shared before it’s finalized, as a preliminary note? Do the patients with caregivers and family members, do they get access? Because oftentimes, they help with health literacy and support. So if you have automatic access to your mom’s record, do you get access to her notes? And lastly, teenagers—how do you negotiate what to do with pre-adults? So these are things to consider that are important configuration, and almost cultural, considerations. And based, on your organization and the willingness and openness of your organization, there’s a spectrum of choices there.

Would you agree that OpenNotes is one element in a bigger picture going forward?

I do agree that it’s one element in a bigger picture. In fact, OpenNotes 2.0 is being termed ‘OurNotes,’ in terms of its creating agenda-setting with the patient. Even before the patient comes to the clinic for a visit, they can log into their portal and do this on an iPad while in the waiting room, and can list for the doctor what they want to talk about during their visit. We’ve tried this in an open-ended way, for discussion between the doctor and patient during the visit. The physician then takes that information and uses it in the clinical note. And then when it’s all done, the patient gets a copy of that final note, for co-signature.” Though the initial pilot project has been small-scaled, Erskine believes that the “OurNotes” experiment points the way towards a new chapter in physician-patient relations going forward.

OpenNotes is part of a larger shift of the relationship between providers and patients, correct? In fact, consumers interacting with nearly all other industries are setting the terms for their interaction. Why should healthcare ultimately be any different?

It’s hard to argue with that; I think you’re right on target. And this notion that patients come to us on our terms, on our schedules—you know, when I was in medical school, if you said the word ‘consumer,’ that was anathema. Now, patients are in high-deductible health plans, and they are using Uber and Amazon and everything. When people go to Ritz-Carlton, they already know about them. And I think that what we’ll see, and what we’re pushing for at Geisinger, is health systems that don’t look at one patient at a time, they look at cohorts of patients, and then beyond that, the entire community of people in their area, those who are coming to them for care and those who aren’t. It’s typically the pre-sick who don’t engage, whom we could potentially engage before they become sick. So we all need to bring that into healthcare, figure out a way to interact with patients, how they want to be communicated with and treated, and put that into the system, the preferences, the same way as in other industries.

When healthcare ultimately gets there, that will be amazing, right?

Yes. And some health systems will get there, and some won’t. And it will be a market differentiator.


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Gazing Into the Crystal Ball with LRVHealth’s Keith Figlioli

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2019 Predictions on Value-Based Care, Digital Startups, EHR Trends

Here’s a confession: I am much better at writing end-of-year review stories than I am at looking into the crystal ball for preview pieces at the beginning of the year. I might be able to make educated guesses about which issues we will be writing about in the coming year, but I prefer leave predictions about what is actually going to happen to others.

Luckily, people braver and more knowledgeable than I am are willing to weigh in. For instance, Dave Levin, M.D., chief medical officer of Sansoro Health recently shared his predictions for 2019 with Healthcare Informatics. One of his predictions is that “the excitement around new health IT players like Apple and Amazon will fade in late 2019. We need fresh ideas, but in the short-term, expect disappointments and missteps. Health IT (and healthcare in general) is much harder than it looks and the winners in the long-run will master the mash-up of the best of old and new. Health IT history is littered with companies like these that underestimate this challenge.” Good point!

Dave’s company, Sansoro Health, provides a set of APIs that read and write to EHRs. One of its investors is Boston-based LRVHealth, and one of LRVHealth’s general partners is Keith Figlioli, who served as senior vice president of healthcare informatics at Premier Inc. for nearly a decade. In December I spoke with Keith about some of his predictions for 2019.

One is that capital will be less abundant for digital health startups in 2019. I asked him why he thought that would be the case. “There already is a tremendous amount of capital in this space, including capital coming from other industries. The threat is that capital could be less abundant,” Figlioli said. “We are starting to see earlier stage companies have a little harder time raising capital. What that signals to us is that the greater market is pushing capital to later stages. Because capital can be harder to get in earlier rounds, valuations tend to float down a bit. The other thing is that the greater macro economy does feel like things are shifting a bit and that will also have an effect. I think 2019 may be a peaking year for valuations. I don’t think we are going to go much higher than we are right now.”

While Dave Levin had predicted that the enthusiasm about outside disruption from Big Tech might fade by the end of 2019, Figlioli predicted that these emerging entrants will start showing their cards. “Some of these guys are fairly secretive in their moves, but Apple has been hiring in healthcare and Amazon acquired PillPack. My sense is that we are going to know more about the ones that have been secretive,” he said. Now that the CVS/Aetna deal is done they will start to reveal more, he added. “We are going to see more announcements from these players over the course of 2019. People will be able to start deciphering what their plans are, at least out of the gate.” With its leadership in place, the Amazon/Berkshire Hathaway/JP Morgan entity will reveal an initiative, he predicted.

He also noted that Walgreens made some strategic announcements in 2018. “I call them the sleeping giant now, because CVS and Aetna made all the noise with their purchase deal. But Walgreens is making some very calculated moves with the incumbent players.”

Figlioli predicts that in 2019 the pace will pick up again on value-based care activity. “At LRVHealth, we have a saying that value-based care is inevitable but it is gradual,” he said. “I think we are finally going to get back up on the hamster wheel with things that really matter, because it feels like we have basically been at a dead stop since Trump took office.” He expects to see a handful of new mandatory and voluntary programs across cancer, cardiac and new bundled payment models. “When [HHS Secretary] Azar came in, it revved the engine back up and he is talking very publicly about ramping up mandatory programs. I think another signal is him talking more about CMMI [the Center for Medicare & Medicaid Innovation] and what may come out of it in terms of social determinants of health. I think we will see one or two CMMI pilots in 2019 dedicated to social determinants.”

In a related prediction, he said we should expect to see community programs such as local food banks become more closely affiliated with healthcare providers and payers. And just as there have been startups in the transportation area of social determinants, expect to see a few food-as-medicine related startups emerge in 2019, he added.

Figlioli’s final prediction touches on something I have written about a few times, the new “app store” approach to EHR add-ons. With open APIs gradually becoming the norm, he said, more CIOs who will become comfortable layering best-of-breed applications on top.

“There has been this lure in the CIO suite to say that the EHR vendor is going to do everything.  But because of what Cerner and Epic are doing and what athena has done all along, we are finally getting to a place where the average CIO is going to going to be OK going back to more of a hybrid model.” He stressed that the core EHR is not going anywhere. “You can think about them the same way you do about ERP systems. Over the last five years there has been a proliferation of overlays on top of them. And I feel like we are finally going to get to that with the EHR. It is not going to be clean or easy. There are going to be issues. It is going to be a pretty messy situation depending on how FHIR gets implemented. But it will become more of a cultural norm that Epic and Cerner don’t have to do everything. CIOs will say, ‘we are OK with them being our core workflow tool, but now we are allowing an overlay to take place.’”




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Research: Physician Burnout is a Public Health Crisis; Improving EHR Usability is Critical

January 18, 2019
by Heather Landi, Associate Editor
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Physician burnout is a public health crisis and addressing the problem requires improving electronic health record (EHR) standards with a strong focus on usability and open application programming interfaces (APIs), according to a new report from leading healthcare researchers.

The report is a “call to action,” the researchers wrote, “to begin to turn the tide before the consequences grow still more severe.” The researchers also recommend “systemic and institutional reforms” that are critical to mitigating the prevalence of burnout.

The result of collaboration between researchers with the Massachusetts Medical Society, the Massachusetts Health and Hospital Association, the Harvard T. H. Chan School of Public Health, and the Harvard Global Health Institute, the report's aim is to inform and enable physicians and health care leaders to assess the magnitude of the challenge presented by physician burnout in their work and organizations, and to take appropriate measures to address the challenge, the researchers say.

The report also offers recommended actions for healthcare leaders to take, which the researchers acknowledge are not exhaustive, but “represent short-, medium-, and long-term interventions with the potential for significant impact as standalone interventions.”

The authors of the report include Ashish K. Jha, M.D., the K.T. Li Professor of International Health at the Harvard T. H. Chan School of Public Health, and director of the Harvard Global Health Institute; Andrew Iliff, lead writer and program manager, Harvard Global Health Institute; Alain Chaoui, M.D., president of the Massachusetts Medical Society; Steven Defossez, M.D., vice president, clinical integration, Massachusetts Health and Hospital Association; Maryanne Bombaugh, M.D., president-elect, Massachusetts Medical Society; and Yael Miller, director, practice solutions and medical economics, Massachusetts Medical Society.

In a 2018 survey conducted by Merritt-Hawkins, 78 percent of physicians surveyed said they experience some symptoms of professional burnout. Burnout is a syndrome involving one or more of emotional exhaustion, depersonalization and diminished sense of personal accomplishment. Physicians experiencing burnout are more likely than their peers to reduce their work hours or exit their profession, according to the report.

By 2025, the U.S. Department of Health and Human Services predicts that there will be a nationwide shortage of nearly 90,000 physicians, many driven away from medicine or out of practice because of the effects of burnout.  Further complicating matters is the cost an employer must incur to recruit and replace a physician, estimated at between $500,000-$1,000.000. 

“The growth in poorly designed digital health records and quality metrics has required that physicians spend more and more time on tasks that don’t directly benefit patients, contributing to a growing epidemic of physician burnout,” Dr. Jha, a VA physician and Harvard faculty member, said in a statement in a press release accompanying the report. “There is simply no way to achieve the goal of improving healthcare while those on the front lines – our physicians – are experiencing an epidemic of burnout due to the conflicting demands of their work. We need to identify and share innovative best practices to support doctors in fulfilling their mission to care for patients.”

The beginning of the physician burnout crisis can be traced back to several events, according to the researchers, including the “meaningful use” of electronic health records, “which transformed the practice of many physicians, and was mandated as part of the 2009 American Reinvestment and Recovery Act.” Going back further, the 1999 publication of the Institute of Medicine’s “To Err is Human” highlighted the prevalence of medical errors, brought new attention to quality improvement and the value of physician reporting and accountability, the report states.

The researchers note that the primary impact of burnout is on physicians’ mental health, “but it is clear that one can’t have a high performing health care system if physicians working within it are not well. Therefore, the true impact of burnout is the impact it will have on the health and well-being of the American public,” the researchers wrote.

The researchers note, “If we do not immediately take effective steps to reduce burnout, not only will physicians’ work experience continue to worsen, but also the negative consequences for health care provision across the board will be severe.”

And, while individual physicians can take steps to better cope with work stress and hold at bay the symptoms of burnout, “meaningful steps to address the crisis and its root causes must be taken at a systemic and institutional level,” the researchers wrote.

According to the researchers, the primary drivers of physician burnout are structural features of current medical practice. “Only structural solutions — those that better align the work of physicians with their mission — will have significant and durable impact,” the researchers wrote in the report.

To that end, the researchers’ immediate recommendation is for healthcare institutions to improve access to and expand health services for physicians, including mental health services.

In the medium term, technology can play a large role. Addressing physician burnout will require “significant” changes to the usability of EHRs, the researchers wrote, including reform of certification standards by the federal government; improved interoperability; the use of application programming interfaces (APIs) by vendors; dramatically increased physician engagement in the design, implementation and customization of EHRs; and an ongoing commitment to reducing the burden of documentation and measurement placed on physicians by payers and health care organizations.

New EHR standards from the Office of the National Coordinator for Health IT (ONC) that address the usability and workflow concerns of physicians are long overdue, the researchers state. One promising solution would be to permit software developers to develop a range of apps that can operate with most, if not all, certified EHR systems, according to the report. The 21st Century Cures Act of 2016 mandates the use of open APIs, which standardize programming interactions, allowing third parties to develop apps that can work with any EHR with “no special effort.” There already have been efforts on this front, such as Epic’s “App Orchard,” the researchers note, but more work remains to be done.

To expedite this critical process of improvement, the report recommends physicians, practices, and larger health care delivery organizations, when seeking to purchase or renew contracts for health IT, adopt common RFP language specifying and requiring inclusion of a uniform health care API.

The researchers also say that artificial intelligence (AI) can play a promising role as AI technologies can support clinical documentation and quality measurement activities.

Long term, healthcare institutions need to appoint executive-level chief wellness officers who will be tasked with studying and assessing physician burnout. Chief wellness officers also can consult physicians to design, implement and continually improve interventions to reduce burnout, the researchers wrote.

“The fundamental challenge issued in this report is to health care institutions of all sizes to take action on physician burnout. The three recommendations advanced here should all be implemented as a matter of urgency and will yield benefits in the short, medium, and long term,” Jha and the research team wrote.


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GAO Report: Patient Matching Efforts Can Be Significantly Improved

January 17, 2019
by Rajiv Leventhal, Managing Editor
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The report did conclude that no single effort would solve the challenge of patient record matching

There is a lot that can be done—such as implementing common standards for recording demographic data—to improve patient matching, according to a new Government Accountability Office (GAO) report that closely examined the issue.

The 21st Century Cures Act included a provision for GAO to study patient record matching, and in this report, GAO describes (1) stakeholders' patient record matching approaches and related challenges; and (2) efforts to improve patient record matching identified by stakeholders.

The 37 stakeholders that GAO interviewed, including representatives from physician practices and hospitals, described their approaches for matching patients' records—comparing patient information in different health records to determine if the records refer to the same patient.

The respondents explained that when exchanging health information with other providers, they match patients' medical records using demographic information, such as the patient's name, date of birth, or sex. This record matching can be done manually or automatically. For example, several provider representatives said that they rely on software that automatically matches records based on the records' demographic information when receiving medical records electronically.

Stakeholders further said that software can also identify potential matches, which staff then manually review to determine whether the records correspond to the same patient. They said that inaccurate, incomplete, or inconsistently formatted demographic information in patients' records can pose challenges to accurate matching. For example, records don't always contain correct information (e.g., a patient may provide a nickname rather than a legal name) and that health IT systems and providers use different formats for key information such as names that contain hyphens.

Those who GAO interviewed identified recent or ongoing efforts to improve the data and methods used in patient record matching, such as the following:

  • ·         Several stakeholders told GAO they worked to improve the consistency with which they format demographic data in their electronic health records (EHR). In 2017, 23 providers in Texas implemented standards for how staff record patients' names, addresses, and other data. Representatives from three hospitals said this increased their ability to match patients' medical records automatically. For example, one hospital's representatives said they had seen a significant decrease in the need to manually review records that do not match automatically.
  • ·         Stakeholders also described efforts to assess and improve the effectiveness of methods used to match patient records. For example, in 2017 the Office of the National Coordinator for Health Information Technology (ONC) hosted a competition for participants to create an algorithm that most accurately matched patient records. ONC selected six winning submissions and plans to report on their analysis of the competition's data.

Those who were interviewed said more could be done to improve patient record matching, and identified several efforts that could improve matching. For example, some said that implementing common standards for recording demographic data; sharing best practices and other resources; and developing a public-private collaboration effort could each improve matching.

Stakeholders' views varied on the roles ONC and others should play in these efforts and the extent to which the efforts would improve matching. For example, some said that ONC could require demographic data standards as part of its responsibility for certifying EHR systems, while other stakeholders said that ONC could facilitate the voluntary adoption of such standards. Multiple stakeholders emphasized that no single effort would solve the challenge of patient record matching.

To this end, a recent report from the Pew Charitable Trusts outlined several key themes related to patient matching, while also suggesting recommendations to improve matching and the infrastructure needed for more robust progress in the medium and long term.

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