One CMIO's experience with OpenNotes

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Source: GE Healthcare

OpenNotes was first launched as a year-long pilot program involving physicians from Beth Israel Deaconess Medical Center in Boston, the Geisinger Health System in Danville, Penn., and the Harborview Medical Center in Seattle. Since then the initiative has grown rapidly and now reaches millions of patients from a number of high profile health systems and institutions. For example, just this past April Kaiser Permanente Northwest began providing its nearly 500,000 members with online access to the notes written by their clinicians. Michael McNamara, MD, Chief Medical Information Officer at Kaiser Permanente Northwest took some time recently to discuss his system’s implementation of OpenNotes.

Can you tell us about the decision making process behind the decision to deploy OpenNotes?

McNamara: When you talk to people about this it’s clear that physicians are generally leery of the whole idea of becoming that transparent to the patient.

What we did very well, I think, was not to make this an informatics problem, but an operational leadership problem—Is this the way we want to be caring for our patients?

About a year ago I was able to get in front of our primary care leadership along with Tom Delbanco (co-director of the OpenNotes initiative), but most importantly we had our patient advisory council in the room. And it became very clear once you talked to patients that this was something they saw value in. So we laid a scientific foundation for the conversation—and this is really where Tom’s group has done some great work in answering some of those questions—but having our own patients come to the table and talk about the value they see in knowing the conversations they have with clinicians captures their concerns and in knowing they can see their information and recommendations was a very powerful tool.

So when our leadership was able to hear about the scientific basis for OpenNotes, that other organizations like the VA had already done this successfully, and that our patients feel that this is a core value to them, then they decided they were all in and were going to do it for primary care. And when we brought it before the leadership of the entire medical group they decided it wasn’t going to be just for primary care, but that it was going to be done for everybody.

It was actually all a bit startling because it's not the norm to be all in on something that from the physician side is sort of transformational. But when I think back on why that happened I think it was because we were able to bridge the gap between their concerns and fears and what the patients really want.

Was it difficult to get your physicians on board?

McNamara: Once we got the leadership involved, then you had to deal with the entire medical group—roughly 1,100 clinicians. And change is hard and helping people to understand the rationale behind it can be difficult.

The nice thing about physicians is that they are very smart and they can get past all the emotion [involved with change] if you present them with a very clear and compelling case about why it’s a good thing for care, why it’s good for patients, and why it’s good for our organization to be in front of something like this. And while we don't know what Meaningful Use is going to morph into over time, it has forced our hand on transparency and it’s probably going to stimulate us to do more and more.

It’s not like there has been complete acceptance that this has been the right thing to do. But the reality is that since April 8, when we flipped the switch and went live [with OpenNotes] for the entire region, I’ve heard virtually no concerns or complaints coming from the medical group side. It’s really been a non-event for us. That doesn’t mean that if I bring the topic up they won’t have some thoughts to share or questions to ask. This can be a very vocal group of people if they are unhappy or have concerns about things.

What are some of these concerns and how do you help clinicians deal with them?

McNamara: We tried to help them understand potential problem areas up front and gave them recommended talking points on specific areas like mental health and obesity.

I think one of the most challenging things for a clinician is that when they are in the middle of working up a problem, but don’t really know what a patient has, they tend to use notes as a scratch pad to write down their thoughts about what their next steps will be depending on how the work up proceeds. And there can be concerns about how [OpenNotes] can interfere with the way in which they’re thinking about the patient.

Our recommendation for almost all of these issues is that they really shouldn’t change what they do. The patient has always had access to the records, so it’s not like they are getting something they’ve never had. It’s just making it more immediate and obvious. However, if there are concerns about specific situations—someone comes in with concerns about domestic violence or something along those lines—clinicians have the ability to hide that particular note at that particular time if they so choose. But that’s a relatively uncommon thing.

What should the CMIO role be in move towards adoption of OpenNotes?

McNamara: I actually see them as the central figure in all of this. I know every organization is a little bit different, but I see my role as an extension of our care delivery and operations and not as a technology person. So, as part of that group I was best situated to understand the issues around OpenNotes and provide the guidance to our leadership to get them to make that decision [to deploy OpenNotes].

Other organizations may have CMIOs who are more part of the IT structure and not as integrated into care delivery itself. But for my purposes it’s been a perfect fit—being part of an operational team to help make changes like this.

What are the kinds of questions you get asked by your colleagues about OpenNotes?

McNamara: If there is any one thing that people ask me it is why we send patients an email telling them to look at their notes at the end of a visit. Isn’t it good enough just to make the note available and if the patient wants he can just go and get it?

For me the issue is that for the patient the whole value [of OpenNotes] is seeing that information. If they don’t get the opportunity to see the information, then why bother doing it at all? Patients are busy like everybody else, and if we think that giving them the information is important, why not provide them with tools to remind them that the information is there?

How have your patients reacted to OpenNotes?

McNamara: We’ve had meetings with our patient advisory council—the same group of patients who helped move us ahead in the first place—and it’s very clear that they continue to see it as a benefit.

For example, let’s say a patient takes a note that has his BMI (body mass index) and plan on it, which they put on the refrigerator because they want to make sure they don’t move into a diabetic state when there is a concern that might happen. Seeing the words of the clinician and being able to put it right in front of the patient in a very visible way has definitely modified behavior.

Probably within the next month we’ll be doing a more formal survey-based outreach to patients and try and ask some of the same questions that Dr. Delbanco asked. We are one small part of a very large organization and at this point we are the only arm of Kaiser Permanente that has fully deployed OpenNotes. We are not trying to change how we are doing things, but we do hope the information we get from our patients will be what is needed to start moving [OpenNotes] forward in the other regions of Kaiser Permanente as well.