As CMIOs and other medical informatics leaders gather together in Ojai, California, for the 25th Annual Physician-Computer Connection Symposium, sponsored as every year, by AMDIS (the Association of Medical Directors of Information Systems), one of those who will be speaking at the conference, to be held at the Ojai Valley Inn and Spa, will be Homer Chin, M.D., who until May 2013 was CMIO of Kaiser Permanente Northwest. The Portland, Ore.-based Dr. Chin remains an affiliate faculty member at Oregon Health and Sciences University. And he is the physician champion for the Northwest OpenNotes Consortium, a group of about 40 clinical informatics leaders in the Pacific Northwest, representing 11 health systems in the metropolitan area that encompasses Portland, Oregon and Vancouver, Washington, and which came together in 2013 to collaborate to promote the OpenNotes movement.
Dr. Chin has been helping to lead forward the Northwest OpenNotes Consortium for three years now, since, at the point of his retirement from Kaiser Permanente Northwest, he was asked to lead the Consortium, which is promoting patient care organizations’ opening physician notes to patients. His title with regard to OpenNotes is Associate in Health Information Technology for OpenNotes.
Indeed, Dr. Chin, together with Alistair Erskine, M.D., CMIO of the Danville, Pa.-based Geisinger Health System, and the Portland-based John Santa, M.D., who until recently was director of the Consumer Reports Health Ratings Center, will speak on that very topic at the AMDIS Symposium this month. In that regard, he spoke recently with HCI Editor-in-Chief Mark Hagland about the OpenNotes movement, and what’s been learned at the Pacific Northwest OpenNotes Consortium, at Kaiser Permanente Northwest, and elsewhere about this important movement. Below are excerpts from that interview.
What was the original purpose, as you and colleagues from numerous health systems in your area gathered together three years ago, in creating the Pacific Northwest OpenNotes Consortium?
To begin with, we had asked Tom Delbanco, M.D. and Janice Walker, R.N., the co-directors of OpenNotes, to come out to talk with us, back in 2013. And after hearing from them, we decided to foster a collaboration among these normally competitive organizations, and move forward as a community. And one of the questions was, could we accelerate OpenNotes adoption collaboratively? And the answer was yes. They all agreed, and one of the things that we strategically put into place was that we said, we’re going to release a press release—we chose April 8, 2014 as the date for that announcement—and we said, if you want to be in the press release, you had to commit to implementing OpenNotes in 2014 or soon after. So that sort of spurred them on, and if they were willing to commit, they were in the press release, and if not, they wouldn’t be included. So most organizations did commit.
What were the processes like among those organizations, as they prepared to meet that date?
Well, once they decided, yes, we’re going to go forward, then Kaiser-Northwest, where I had just stepped down as CMIO, said, they were willing to go “big bang” with the implementation. Most organizations did so with small pilots. But my colleagues at Kaiser-Northwest just said, there’s enough evidence for this, and let’s just do it. So Tom and Jan came back and talked to Kaiser-Northwest, and help lead education and persuasion. And at Kaiser-Northwest, they decided to go ahead and implement it in April 2014, for their entire organization except for a few departments like mental health.
Was there any anxiety or resistance initially among physicians at Kaiser-Northwest?
Well, among the chiefs of the departments, when they saw the data, they agreed that we needed to do this. In the rank and file, some physicians weren’t as enthusiastic about OpenNotes, so one of the they things they decided was that the default would be availability to patients, but in a way that allowed for a box that opted out of a particular note that couldn’t be shared. So for those physicians feeling resistance, that gave them the option.
And what percentage clicked the box, and kept their particular notes closed?
Initially, it was a quarter of one percent. And that number has further decreased. It’s a very small percentage of one percent.
In other words, once they went live at Kaiser-Northwest, the physicians were happy and satisfied with it?
I would say, by and large. The thing that we hear is that it was a non-event. Physicians have a lot of reservations, but then you open up the medical record, and physicians concede that they haven’t heard anything about it. Occasionally, we get one physician here or there who reports that a couple of patients have complained. But the predominant thing we hear is that it was a non-event. And from the patient perspective, it’s all positive. So we’ve heard a lot of positive things that replicate the original studies, which find patients are more likely to be engaged in their care, more likely to take their medicines; their opinion of the healthcare system goes up, they’re more likely to approve of their physicians. And that happens with every organization that goes live.
Those were some of the main points you brought forward when you spoke at the AMDIS PCC Symposium last year?
Yes, we talked about that, and then we had some folks from Legacy Health as well. We had four or five physicians on a panel, talking one after the other, from various health systems. The panelists besides myself were John Santa, M.D., Michael McNamara, M.D., and Amy Chaumeton, M.D.
And this year?
This time, we [Drs. Chin, Erskine, and Santa] are going to talk about where we are. We’ll talk about our experience; we’ll reinforce the fact that it’s really a non-event when organizations go live with OpenNotes. And we’ll talk about some of the positives. Physicians worry that it will require more work of them; we’re seeing some evidence that it actually entails less work for them. One survey asked, are you contacting your doctor more or less often? A certain percentage contact their doctor more often, a certain percentage report no change, but the percentage who say they’re contacting their doctor less often, is higher than the percentage who are contacting their doctor more often.
What is your theory on that? Those are patients who are contacting their doctors less often are individuals who would have been confused about or would have forgotten something their doctor said?
That’s right. And so we’ll give an update there, and then we’ll talk about what some of the other organizations are doing. Some are doing things a little differently sometimes, or more innovatively. And Alistair Erskine is going to talk about the experience at Geisinger, which is one of the organizations that implemented OpenNotes earlier, and are doing some things around inpatient OpenNotes, using a thing called MyChart Bedside, where they give patients an iPad at admission that allows them to check things while they’re hospitalized, and then the patients are sent home with, for example, videoconferencing built into the iPad. And they’re collaborating together, physicians and patients, on something called OurNotes, which is a collaboration between the patient and physician in doing the note together, if you will.
Overall, what would you like other medical informaticists, and non-clinician IT leaders as well, to know about all of this?
Overall, that this is coming; this is becoming more standard, it’s no longer on the fringe. Our estimate is that more than 7 million patients now have access to their notes. Most of the pieces are there, as long as they have Epic or Cerner; while many other vendors are moving forward with the capability. Allscripts is another one that has the capability, and that has some user organizations implementing OpenNotes. There are organizations we’re talking to that are Allscripts organizations. So the message is that the capability exists, and it’s becoming the standard of care. And there are advantages to organizations that implement this in terms of attracting patients. And there are potential patient safety benefits. And CRICO, the insurer for Harvard Health Plan, is looking into this.
It seems clear here that any challenges to implementing OpenNotes really revolve around physician culture issues, not actual technological issues, correct?
Yes, to me, the number-one thing is overcoming physician resistance. You need the technological elements, but what’s hardest to overcome is physician resistance. And even though some physicians have a concern, it ends up being a non-issue. So it’s a win-win all around. It helps with keeping patients in the health system, and attracting patients, and it may help with patient safety—it’s another set of eyes looking at the medical record. And in fact, by and large, it may make the life of the physician easier. The cost is negligible, and it’s becoming the standard of care. So what’s not to like about it?
And we’ll share examples of where Geisinger and the University of Iowa are moving with this; the University of Iowa has basically opened its entire outpatient and inpatient record to patients. And the VA has been doing this for years and years. I think it was back in 2010… The VA was an early adopter of Blue Button, and with Blue Button, VA patients have access to and can download, their entire medical record. And when we did our Consortium, the VA was actively engaged as well. And they were very helpful in saying, we’ve been doing this for years and years. So they were helpful in bolstering the case for moving forward in this direction.
One element of natural dovetailing here seems to be around the fact that patients/consumers are being pushed ever more aggressively by their employers into higher-deductible health plans, in which they are burdened with ever-higher percentages of their healthcare costs. Naturally, they’ll want to better understand the components of their care and to become more directly engaged in all this, right?
Yes, you’re absolutely right.
And what would you say to non-clinician IT and executive leaders about the OpenNotes phenomenon.
Exactly what you said earlier, that this is coming now, and they need to prepare for this. And we’ll be presenting as well at the CHIME Fall Forum in November (to be held in Phoenix, and sponsored by the Ann Arbor, Mich.-based College of Healthcare Information Management Executives). And I’ll be co-presenting with John Kravitz in November, on this. And now that AMDIS and CHIME are working together, AMDIS is going to have a session right after the CIO Fall Forum, so we’ll probably present there as well.