Thomas Yackel, MD, MPH, MS & Susan Woods, MD, MPH

Toward Transparency and Trust: A Conversation about OHSU and the

Portland OpenNotes Collaborative

Conflict of Interest Disclosure

Disclosure – Susan Woods

I do not have any relationship(s) to disclose.

Disclosure – Thomas Yackel

I do not have any relationship(s) to disclose.

Agenda

• Audience response system overview• Introduction to OpenNotes• OpenNotes: history, research, and

experiences at the Portland VA• OpenNotes at OHSU• Conversation and audience response on

next steps

I think sharing progress notes with patients in MyChart is a good idea

A. Strongly Disagree

B. Disagree

C. Agree

D. Strongly Agree

Indicate your agreement with the statement

OpenNotes: history, research, and experiences at the Portland VA

40 years ago, there was a “Proposal”

Shenkin B, Warner D. New England Journal Medicine 1973

• Enhance patient autonomy

• Improve patient-physician relationship

• Serve as educational tool

Bhavnani et al. Family Practice 2010; 28:188-19423

3 London practices gave record access -HealthSpace

Results: 86% accessed records Age, ethnicity not associated with frequency Poorer health - more frequent access 38% found errors (48% did not take action) 76% felt more involved in care 9% more worried about health 75% felt more confident in GP (3% less confident)

Shared NHS Electronic Records

10Woods SS, Schwartz E et. al. J Med Internet Res 2013;15(3):e65

It’s a Communication Tool

“I can go in and ask more intelligent questions and we don’t have to spend as much time with

them explaining everything to me.”

Woods SS, Schwartz E et. al. J Med Internet Res 2013;15(3):e65

It boosts self-care.

“Made me feel more responsible for myself, like there’s no excuses. You know, it’s right there, you

know. You can’t use ‘the doctor didn’t tell you’.”

“You could pop over to Google or the library, and see what it’s saying instead of sitting there sweating it out trying to figure out what it is.”

Woods SS, Schwartz E et. al. J Med Internet Res 2013;15(3):e65

It improves quality.

“An ultrasound on my liver said….‘Re-do in 6 months’. Six months came, nothing happened. So I called the doctor. He says, ‘Yeah, they did say that’. So, if I hadn’t reminded him, I wouldn’t have got it.”

Woods SS, Schwartz E et. al. J Med Internet Res 2013;15(3):e65

It improves quality.

“My Oncologist was up-front guy, he wasn’t as up front as I thought, with what he wrote. I said to him, ‘I’d like to know what you think, what you know, and what you’re predicting. Rather than just write it in there, tell me - and then write it’.

Woods SS, Schwartz E et. al. J Med Internet Res 2013;15(3):e65

Observations on Notes & Records

• Language

• Errors

• Inconsistencies

• ‘Boiler plate’

• Stress with full disclosure– But better to have it all, then none

http://www.slideshare.net/ReginaHolliday/vision-14132302#btnNext

http://reginaholliday.blogspot.com

73 cents, Regina Holliday, Patient Advocate, Artist

Open Notes Study

• Robert Wood Johnson Foundation Pioneer Portfolio• Beth Israel Deaconess, Harborview, Geisinger• 100 Primary Care providers and >13,000 patients• Email notification with new note upload• 2010 to 2011 (access continues)• Baseline and follow-up surveys

Delbanco T, et.al. Ann Intern Med, October 2, 2012 157(7):461-470

% Agree

Patients PCPs

Takes better care of self 70 28

Better understand conditions 84 41

Remembers care plan better 84 44

More prepared for visits 73 36

More in control of care 84 49

Take medications better 60 31

Patient and PCP Views of Open Notes after 1 Year

Delbanco T, et.al. Ann Intern Med, October 2, 2012 157(7):461-470

% Agree

Patients PCPs

Felt offended 2 8

More confusing than helpful 3 21

Worries more 7 42

Concerned about privacy 32 --

Patient and PCP Views of Open Notes after 1 Year

Delbanco T, et.al. Ann Intern Med, October 2, 2012 157(7):461-470

23

MyHealtheVet Blue Button Survey

June – Sept. 2013

Preliminary data – from My HealtheVet personal health record users, on early use of Blue Button and OpenNotes…

Use of Blue Button to access notes

PercentWhat’s Blue Button? 28%Not sure 27%I viewed notes once or more 25%I tried to 13%

Information viewed using Blue Button

Response PercentVisit notes – primary care 69%Visit notes – med/surg specialty 40%Secure messaging note 34%Visit notes – mental health 19%Hospital visit (ER) or stay 15%Don’t know or remember 14%

WHY did you read your visit notes?

Response Percent

To know more about my health 25%

I was curious 20%

To understand what my provider said 20%

To remember what was said at visit 12%

Check to see if notes are right 9%

To know what my provider is thinking 6%

12% talked with health team member

12% plan to talk with health team member

If YES:

53% To learn more about my health issue

34% To get an explanation on something in note

22% To discuss something I was worried about

21% To discuss something I though not correct

74% did not/no plan to talk with health team

• 82% had no reason to• 5% didn’t want to waste their time• 5% didn’t think it was important

Do notes correctly describe visit?

Pretty Well Mostly Disagree Don't Know0

20

40

60

80

Are OpenNotes Really New?

OpenNotes Pilot at OHSU

What does OpenNotes Look Like at OHSUfor Providers?

What does Open Notes look like for patients?

What does Open Notes look like for patients?

What are other institutions doing?

Consumer Reports’ Portland Challenge

What are the advantages and disadvantages?

What would the principle advantage be?

A. Improved patient understanding/participation/adherence

B. Improved note completion time, accuracy, completeness

C. Reduced medical errors

D. Greater patient trust/appreciation

E. Facilitation of pt note sharing with others

What would the principle disadvantage be?

A. Patient confusion, pressure, anxiety

B. Privacy problems

C. Patient offended by what is written

D. Unwelcome changes in documentation

E. Need for additional documentation time

I think sharing progress notes with patients in MyChart is a good idea

A. Strongly Disagree

B. Disagree

C. Agree

D. Strongly Agree

Indicate your agreement with the statement

Additional Discussion Questions

• Is this a good idea for OHSU?• Should OHSU “sign on” to the Portland

Open Notes consortium?• How should OHSU go about deciding how

to implement OpenNotes?– Opt In, Opt Out, who gets to decide?

• What are the next steps in this conversation?