OpenNotes and Patient Engagement in a Safety-Net Environment: One MD Informaticist’s Journey | Healthcare Informatics Magazine | Health IT | Information Technology Skip to content Skip to navigation

OpenNotes and Patient Engagement in a Safety-Net Environment: One MD Informaticist’s Journey

February 21, 2018
by Mark Hagland
| Reprints
Anshu Abhat, M.D., of the Los Angeles County Department of Health Services, is spearheading an exciting patient engagement initiative

Much of the attention around the OpenNotes movement, which gives patients direct access to parts of the physician documentation in their electronic health records (EHRs), has been around private health systems. But what about OpenNotes, in the context of the public hospital-/safety-net hospital-based healthcare system? Don’t the patients in public hospitals and clinics also deserve enhanced access to their own healthcare information?

The answer to that question, according to leaders in the Los Angeles County healthcare system, is a resounding “yes.” Los Angeles County’s four hospitals and 18 clinics are moving forward to provide increased patients’ access to their own health records, within the broader context of efforts to engage patients in order to enhance their health status.

Indeed, leaders at that county healthcare system have made a commitment to engage their patients far more fully in their care and health, recognizing the complexities of doing so when engaging populations facing issues around poverty, transience, social instability, and other challenges in their lives.

At Los Angeles County Department of Health Services, Anshu Abhat, M.D., M.P.H., the director of patient engagement in information technology, has been helping to lead a patient engagement initiative, one in which information technology has proven to be a vital facilitator of progress in this area. Dr. Abhat, a general internist who continues to practice primary care medicine at Harbor-UCLA Medical Center in Torrance, and in Harbor-UCLA’s outpatient clinics, and who teaches residents there in both the inpatient and outpatient settings, has been working with a variety of colleagues across the public hospital system to move things forward around IT-facilitated patient engagement. She spoke recently with Healthcare Informatics Editor-in-Chief Mark Hagland about this initiative, and its implications for patient engagement efforts healthcare system-wide. Below are experts from that interview.

Your team is a somewhat virtual, project-specific one?

Yes; my team was blank in the beginning. I work with a variety of different individuals in different areas within the system. There are the IT folks—I collaborate with the CMIOs at the different facilities, including the one over all of DHS, and also IT analysts; I also work with the local operational folks, including the primary care workforce—the primary care physician leaders, and specialty leaders. I also work with our CMO for the county, and more recently, have been working with the folks who handle the patient experience.

What are the backgrounds of the members of the patient experience team?

There’s one designated patient experience person at each of the hospitals. They’re generally not clinicians; some have more MBA backgrounds; others have had operational backgrounds, for example, one was an interim COO.

What areas have you been discussing with colleagues, per the patient experience, and how that might be enhanced?

There’s been a big focus on the social determinants of health side of things, and there are a couple of programs that really have formed our work. There have been a couple of grants, one around Whole Person Care. [As the California Department of Health Care Services notes on its website, “The overarching goal of the Whole Person Care (WPC) Pilots is the coordination of health, behavioral health, and social services, as applicable, in a patient-centered manner with the goals of improved beneficiary health and wellbeing through more efficient and effective use of resources. WPC Pilots will provide an option to a county, a city and county, a health or hospital authority, or a consortium of any of the above entities serving a county or region consisting of more than one county, or a health authority, to receive support to integrate care for a particularly vulnerable group of Medi-Cal beneficiaries who have been identified as high users of multiple systems and continue to have poor health outcomes.”] A grant is being administered by the state of California, with pilots focusing on the most marginalized Medi-Cal patients—homeless high-risk patients, patients involved with the justice system, mental health high-risk patients, substance-abuse high-risk patients, high-risk perinatal patients, and medically high-risk, high utilizers of healthcare. That’s an initiative run by a very innovative team here. So that’s one initiative going on.

How do you interface with them?

They’re fairly early on in working on the grant, about a year in, and they’re working in hospital settings, clinic settings, and in the community, around getting people more involved in their care. I’m starting to explore that with them myself. Right now, I don’t have a direct interface, but they’re doing a lot a work—a project called CHAMP, where they’re creating an EHR that spans all those areas of high risk, beyond the purely medical; I don’t think that’s been done before, so that’s innovative. And we have other folks working on system-wide social-determinant screenings, to better understand patients as they walk through the door. We need to understand which interventions will matter, and the EHR [electronic health record] can help us understand stratification of patients, and where we should focus our health efforts.

What has your particular focus been on as an individual?

It’s been a bit more of a technology focus; a lot of my effort has been around the patient portal, and part of that has been increasing the transparency of data to patients within that. And the big initiative I’ve been involved with has been the launch of OpenNotes. We launched the first phase of it on January 16. The areas we’ve launched have been inpatient, so most of the inpatient documentation excluding progress notes, which tend to be messy, and the emergency department notes, and outpatient specialty notes.

So patients can see all those, since mid-January?

Yes, that’s correct.

How has it gone?

It’s gone well. Like any of these efforts, it took some initial education and work at the beginning, but we haven’t had any issues.

How many patients have accessed their notes so far?

Looking at our stats, in the last month, we’ve had about 4,000 patients who’ve accessed notes.

How many patients ultimately will do this?

I think the majority of patients engaged on the portal, will end up accessing notes. Right now, we have about 30,000 patients on the portal. That’s a small percentage of our total impaneled patients, 500,000 impaneled patients. We vary in terms of the volume of patients who are on our portal, from across our total population—between 6 percent and 25 percent, but looking at the clean numbers, it ends up being about 10 percent who are on the portal so far.

Anecdotally, what have you been hearing from physicians and patients about their experience of OpenNotes?

We haven’t had a lot of discussions directly with patients, but they’ve been largely self-directing. And in terms of physicians, some physicians were initially cautious, but things have gone well. And our oncology group, for example, has been one of the specialty groups that has been most interested in this. One of the challenges you always face in safety-net systems is enrollment, so we’re working on improving our enrollment across the system. We’re now in a project focused on human-centered design, to look at the ongoing efforts across different facilities, and to help us guide them through standard processes. We’re also looking at literacy, language, executive function of smartphone use, etc.

A lot of our patients have smartphones in their possession, but a lot of patients may never have an email address, and this requires that you have an email address. So we have a team of health educators; they are in a lot of our clinic facilities, doing a lot more facilitation with patients, to help them not only sign up but really understand the tool and navigate through it. We also have a group of peer mentors who are actually patients; a lot of them are spinal cord injury patients at our rehab centers, and they work with the hospitals to guide other patients as peers.

Is it because those patients have the available time to participate in that, as they recuperate?

Yes, and they’re also employed by the hospital. At Rancho, they have the peer mentor program. They decided it would be important to have a peer-mentor group. Rancho Los Amigos Medical Center, in Downey.

Much of the high-profile progress of OpenNotes has been in private health systems with mostly middle-class populations. What does the OpenNotes phenomenon look like, from the standpoint of a safety-net health system whose majority population is disadvantaged?

There are challenges, and they’re not well-understood. But there is some evidence in the literature that patients who face barriers, tend to increase their trust with clinicians, when they have notes shared with them. They tend to be patients of lower economic status and also limited English proficiency. So the idea is, sometimes in a public system, this concept of trust can be variable, because of a lot of the barriers that exist—barriers on all sides. So I think that this idea of promoting trust by promoting transparency—that’s where this movement has roots in the safety-net community.

And it’s a very fair question—when you present a Spanish-speaking patient with a note in English, what do you expect will happen? And that’s a very fair question, and we’re actually doing formal research on that. But the basic concept is this: what happens a lot of times is that translation services are variable, what patients walk away with, is variable. And if you can give someone the basis of that communication and of understanding and interpreting that, that’s what we’re exploring.

So some of these patients are already engaged with interlocutors, such as adult children, for example, who are bilingual; so this creates greater transparency?

Yes, the idea is building trust, and increasing the individual’s capacity empowerment around their health, with the understanding that this is something that needs additional study. At the same time, this is your information, and you have the right to this information, and we want to facilitate that as much as possible, and learn how this can help with your health and well-being.

So you’re trying to change the dynamic for patients who come into the healthcare system disempowered to begin with?

Yes, and simply the ability to access this information. If this information comes from your body, it should be available for you to understand. And translation is a big issue in general, and if we ask, how is that relevant to IT? You can imagine a translation tool built in, reading these notes, and giving the patients a translation; and there is some work being done around that. But, absent that, the first layer is saying, this is your health information; you decide who your community is. And we encourage people using proxies, if they are comfortable using them to help them. I have some elderly patients who speak Spanish, and I speak Spanish as well, but often, it’s their adult daughters who serve as caregivers and proxies for them; and with IT, we can actually start to create some formal relationships here. There is a bit of a double-edged sword, because it has to be the right person. But we’re actually identifying those individuals formally, in the system.

What have been the challenges, opportunities, and learnings, for you and your colleagues in this, so far?

Initially, establishing the patient portal, creating OpenNotes, putting radiology reports online—sometimes, these things are not the right place to start, in a safety-net environment. I’m working on text messaging now. In the safety-net environment, text-messaging is a really good place to start. The text-messaging can now feed the portal, and the portal can feed more complexity; so that’s one area. I’ve also done some work around patient education, so I’ve learned about the standards of patient education, and I’m realizing that all of these are quite interconnected: patient education, delivering patient education in relevant, usable ways, like text messaging; and making sure it’s relevant in a literacy perspective, and a language perspective. It’s not like, this is the tool, and everyone can use it; it’s about how you create an environment of literacy around patient care delivery, and text-messaging is a tool to help facilitate that.

What should clinicians, clinical informaticists, and pure IT people, be thinking about, as they move forward with this, around complex populations?

Keep in mind patients’ priorities and preferences, as they manage complex processes. In other words, make all of this as seamless and convenient as possible. The first thing we did around OpenNotes was, we went around and surveyed patients waiting in lines, and found that they were waiting long periods of time to access their doctors’ notes; it was taking time away from their work and families to do this. So whoever you are, when health feels like two extra steps in order to do this, it’s hard when you have to go out of your way to go through processes to support your health. So we need to bring that straight to the patient, and really center our interventions around the patient, or the parent of the patient, and just make it easy.

And the big focus in Los Angeles County, through some of these different initiatives, is taking this traditional model of healthcare delivery, and step back from it and think about other ways to deliver care. We’re doing a lower-tech version of telemedicine with phone visits, decreasing the amount of time they need to drive and park, to access clinic visits.

So the core of all this is, do what’s right for your community, correct?

Yes, absolutely. As we step back from the IT piece, it’s, let’s understand our community, let’s use IT to help tailor things for our patients. So, do a technology assessment, do a literacy assessment, do those things, and let that inform how to best reach people to their convenience.

And it’s helpful that nearly everyone has smartphones, even disadvantaged patients?

Yes, but what you find out is that not everyone can use them in the way you’d think. I’m a leadership fellow with the California Healthcare Foundation—it’s a two-year executive leadership program—and I’ve just done a lot of interviews with patients, and I’m finding out who and who cannot use these smartphones for a variety of purposes. And you start to understand, we really have to capture this information.



2019 Southern California San Diego Health IT Summit

Renowned leaders in U.S. and North American healthcare gather throughout the year to present important information and share insights at the Healthcare Informatics Health IT Summits.

April 23 - 24, 2019 | Southern California


Health Systems Work with Epic on Electronic Patient-Reported Outcomes for Oncology

November 18, 2018
by David Raths, Contributing Editor
| Reprints
With eSyM app, patients will provide feedback to their cancer care team via the EHR

Six U.S. healthcare systems are sharing a $9 million grant to research introducing electronic patient-reported outcomes (ePROs) into the routine practice of oncology providers to improve symptom management and to decrease hospitalizations.

The National Cancer Institute, in association with the Beau Biden Cancer Moonshot Initiative, recently announced the funding of the collaboration, the SIMPRO (Symptom Management IMplementation of Patient Reported Outcomes in Oncology) Research Center. The SIMPRO team will work with Epic, the EHR system used by all six participating institutions, which are New Hampshire-based Dartmouth-Hitchcock, Dana-Farber/Brigham and Women’s Cancer Center in Boston, Baptist Memorial Medical Center in Memphis, Lifespan Cancer Institute in Rhode Island, West Virginia University Cancer Institute, and Maine Medical Center in Portland.

SIMPRO will develop, implement, and evaluate an ePRO reporting and management system through an app called eSyM. Patients’ smart devices will enable a secure connection to their cancer care team via the EHR, and facilitate symptom tracking following cancer surgery or chemotherapy. The study will test whether monitoring the symptoms patients experience and providing coaching on how to manage them can decrease the need for hospitalizations and emergency room visits.

“The opportunity to partner directly with Epic and their resources, to build these tools into our electronic health record, means in the short-term the research is more likely to bear fruit “and in the long-term that successful strategies can be disseminated around the country.” said Dartmouth-Hitchcock Chief Health Information Officer Peter Solberg, M.D., in a prepared statement,

After development and pilot testing, eSyM will be fully integrated into the EHR at each participating center, allowing for direct communication and real-time updates for clinicians who will have access to a dashboard of patients’ symptoms to prioritize outreach efforts and coaching.

The SIMPRO investigators will conduct a randomized trial to evaluate implementation of eSyM from a patient, clinician and health system perspective. Across all study phases, the implementation, adoption, acceptance, and adaptation of the ePRO system will be critically evaluated to promote better delivery of cancer care.



More From Healthcare Informatics


UnitedHealthcare to Award Members with Apple Watches for Meeting Daily Walking Goals

November 16, 2018
by Rajiv Leventhal, Managing Editor
| Reprints

UnitedHealthcare Motion, an employer-sponsored wellness program, is telling its participants they can get a free Apple Watch if they meet the insurer’s daily walking goals over a six-month period.

Participants can start receiving and using the Apple Watch (initially paying only tax and shipping) and then apply program earnings toward the purchase price of the device. Participants may be able to own, with a zero balance, an Apple Watch after approximately six months of meeting daily walking goals, the insurer announced this week. If members already own an Apple Watch, they can use the one they have.

UnitedHealthcare Motion, since 2015, has been providing eligible plan participants access to wearables that may help them earn over $1,000 per year by meeting certain daily walking goals. Since the program’s inception, participants have collectively walked more than 235 billion steps and earned nearly $38 million in rewards, according to officials.

Program participants can now use the Apple Watch to see how they are tracking against the program’s three daily goals—frequency, intensity, and tenacity—helping integrate physical activity and engagement with their health plan.

Indeed, UnitedHealthcare Motion is available to employers with self-funded and fully insured health plans across the country. The program may enable employees to earn up to $4 per day in financial incentives based on achieving FIT goals:

  • Frequency: complete 500 steps within seven minutes six times per day, at least an hour apart;
  • Intensity: complete 3,000 steps within 30 minutes; and
  • Tenacity: complete 10,000 total steps each day.

“This program is part of UnitedHealthcare’s broader effort to provide people with wearables, digital resources and financial incentives that help them take charge of their health, better manage chronic conditions and make care more affordable,” officials noted.

Indeed, these efforts build on UnitedHealthcare’s existing consumer offerings, powered by Rally, which have enabled people to earn more than $1 billion in health-related financial incentives since 2016, the insurer stated.

Among all eligible UnitedHealthcare Motion participants, more than 45 percent participated in the program—compared to some other employer-sponsored disease-management programs that report 5 percent engagement rates.

Among people who registered their device, 59 percent stayed active for at least six months, a rate higher than gym memberships (29 percent). Current program participants walk an average of nearly 12,000 steps, or more than twice the approximately 5,200 steps logged by the average American adult, officials said.

The program has been particularly appealing to eligible participants with chronic conditions. People with such a diagnosis are 20 percent more likely to participate, and people who have diabetes are 40 percent more likely to participate than those who do not, according to the insurer.

As CNBC’s Christina Farr speculated in a story that broke the day before the UnitedHealthcare announcement, “The integration with UnitedHealthcare, which is the largest U.S. healthcare company, could mean a boost in sales of the Apple Watch as more people are able to buy it at an affordable price.”

It was reported last year that another major health insurer, Aetna, which already offers the Apple Watch to its employees as part of a wellness program, has also been in talks with Apple about pushing the wearable device to the health insurer’s members, according to a report in CNBC.

About a month ago, UnitedHealth Group’s CEO said on an earnings call that the insurer would be unveiling a “fully integrated and fully portable individual health record” by the end of next year, with the Rally digital platform serving as the base for development. 

Related Insights For: Patient Engagement


N.Y. Hospital Conducts Digital Assessments of Patient Interactions

November 13, 2018
by David Raths, Contributing Editor
| Reprints
Upstate University Hospital uses Vocera Rounds mobile app to gather data, provide feedback
Click To View Gallery

Physicians at Upstate University Hospital in Syracuse, N.Y., are using a mobile app to collect data about hospitalists’ behaviors during patient interactions in order to provide real-time feedback.

Amit Dhamoon, M.D., Ph.D., internist at Upstate University Hospital and associate professor of medicine at SUNY Upstate Medical University, said he was looking for a way to improve physician-patient communications.

“It is still unclear why some physicians really connect with patients and some just are not able to,” he said. “It is unclear why certain patients trust certain doctors more than others. We want to look at some basic behaviors.”

His team decided to do the digital assessment using a customized version of Vocera Rounds, a mobile application that enables clinicians to collaborate in responding to patient feedback and closing care gaps. “We needed a way to collect the data, relay it, and analyze it,” he said.

Fourth-year medical students who are going into internal medicine join the team of hospitalists on their rounds and serve as “silent shoppers,” Dhamoon said. They focus on the communication aspects of each interaction, and enter their observations into an iPad.  Residents and physicians also use the app to conduct a brief patient survey after the encounter. 

Among other things, they assess:

• how much time the provider was in the room;
• whether the provider introduced themselves;
• whether they sat down at eye level with patient; and
• At the end of conversation, did they ask if there were any questions?

Dhamoon said patients may pick up on body language or other things that physicians are not even cognizant of. “We are focusing on how to treat gall bladder disease or make their pneumonia better. We are focusing on the medicine,” he said. “We have to do that, but we also have to communicate what we are thinking.”

In an academic medical center, it is not unusual for teams of eight to nine doctors, residents and students enter a patient’s room. “Sometimes they don’t know what to do with their hands, so they stand with their arms crossed in front of them,” Dhamoon said. “For the patient, who is lying down with an ailment, it can almost feel like an inquisition.”

Dhamoon says hospital rooms are sometimes cramped and there is not a chair available. “I can say that it should be the gold standard that we are at eye level, so it doesn’t send a message to the patient that we have one foot out the door. But if we don’t have the basic tools in place, like a chair, then it is not going to work.”

Dhamoon and his colleagues are studying the effectiveness of this training approach and its impact on patient satisfaction measured by Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) surveys.  “My colleagues are incredible people. I want our patients to see how incredible they are. We get in our own way sometimes.”



See more on Patient Engagement

betebettipobetngsbahis bahis siteleringsbahis