Susan Woods, MD, MPHDecember 14, 2012

VA Blue Button & Open Notes

VA

2

Patient centered care empowers patients to participate in their

health and healthcare. With more complete access to their health

information, patients can become active partners in their care.

Over 1.9 million registered users 0.9 million authenticated users More than 76 million visits 33.5 million Prescription Refills 479,000 opted in for Secure Messaging

VA Medication History

VA Appointments*

VA Laboratory Results: Chemistry/Hematology*

VA Allergies and Adverse Reactions*

VA Wellness Reminders (MHV Clinical Reminders)*

VA Immunizations*

DoD Military Service Information*

My HealtheVet & VA Blue Button Today

165k Downloads in October 2012

PROBLEMList

DEMOGRAPHICS PROGRESSNotes

MICRO-Biology

VITALS& Readings

PATHOLOGYSurgical,

Cytology, EM

EKGList

RADIOLOGYReports

CONTINUITY of CARE DOCUMENTCDA File

Coming Soon : More VA Data

Blue Button is patient centered,

and directly controlled by the patient.

...permissions & privacy and data-sharing are easier!

PATIENTS & CARE-GIVERS

PROVIDERS

CAREGIVERSAPPS

http://www.healthit.gov/patients-families/video/preview-health-it-you-giving-you-access-your-medical-records

Most patients and doctors agree that patients should be able to download their own health information

www.markle.org/sites/default/files/20101007_bluebutton_summary_1.pdf

All patients have a right to get their health record.

Patients denied or obstructed may file a complaint with OCR.

Office of Civil Rights Memorandum

Stage 12011-2012Post-Visit

Summary

Stage 22014

Secure Patient Messagi

ng+

View, Downlo

ad, Transmit

Stage 32016

Automated Blue Button

Transmit+

Patient-Generat

ed Health

Info

Meaningful Use

GAME CHANGER

AHEAD

Technology changes patients’ lives and role in care.

Shared records: an idea whose time has come.

The evidence is in: benefits are high and risks low.

Veterans Voices: it’s what they want.

It’s time to re-design our work.

Top 5 Reasons for VA OpenNotes

Technology changes patients’ lives, and their role in their care.

 10 Most Common Activities ▼ % Adults who do this▼

Survey Year 

Use search engine 91 2012

Use e-mail 91 2011

Get info on hobby or interest 84 2011

Search for map or directions 84 2011

Check the weather 81 2010

Look for health information 80 2010

Get info on something to buy 78 2010

Get news 76 2011

Go online for fun or to pass time 74 2011

Buy a product 71 2011http://www.pewinternet.org/

What Internet Users Do Online

MyGroupHealth Use Over Time

Ralston JD et al, Health Affairs 2010; 29:607-613

http://participatorymedicine.org/

Shared records aren’t a new idea, but an idea whose time has come.

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

The evidence is in: benefits are high and risks are low.

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

3 London practices gave record access -HealthSpaceResults:

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

Portland

MHV Pilot users

5 focus groups (30+ pts/

caregivers)

Qualitative

Analysis

Patient Perceptions of Full Access to Their Health Records through MHV Pilot

Theme 3: Patient participation in care and quality

Theme 2: Enhanced knowledge and self-care

Theme 1: Better communication with provider, more prepared for visits

Themes – Patient Views

“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. And then, with my stress level up at the doctor’s office, I don’t hear half of it and then we may have to do it again and again and so, it helps us to have better communication”.

Communication…

“Made me feel more responsible for myself too, 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 just pop over to Google or the library, a dictionary in there, and check it out and see what it’s saying instead of sitting there sweating it out trying to figure out what it is.”

Knowledge and Self-Care

“I don’t think I had to go as often [to the doctor] because…yeah, because I could see my results. I could see what was going on and I didn’t, I didn’t get stressed out waiting to hear back from somebody who might never call me.”

Participation in Care – Patient Decisions

“I had an ultrasound on my liver and I saw the results online. It said, ‘Re-do in 6 months’. Well, 6 months came and nothing happened. So I called the doctor and I say, ‘Well, it said here 6 months, re-do’. He says, ‘Oh yeah, they did say that’. So, if I hadn’t reminded him, I probably wouldn’t have got it.”

Patient Participation in Quality - as Reminder

• RWJF Pioneer Portfolio• Beth Israel Deaconess, Harborview, Geisinger• 100 providers and 20,000 patients• Access provider notes through patient portal• Email notification with new note upload• 2010 to 2011 (access continues)• Baseline and follow-up surveys

Open Notes Study

Delbanco T et. al. Ann Intern Med, 2012

% AgreePatients PCPs

Takes better care of self 70 28Better understand health conditions 84 41Remembers care plan better 84 44More prepared for visits 73 36More in control of care 84 49Take medications better 60 31

Patient and PCP Views of Open Notes after 1 Year

Delbanco T et. al. Ann Intern Med, 2012

% AgreePatients PCPs

Felt offended 2 8More confusing than helpful 3 21Worries more 7 42Concerned about privacy 32 --

Patient and PCP Views of Open Notes after 1 Year

Workload

Stress

NotesClinician Concerns

Listen to Patient Voices: it’s what they want.

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

http://reginaholliday.blogspot.com

73 cents, Regina Holliday, Patient Advocate, Artist

Notify me.Let me see all my health records.Help me understand my information.Let me add to the record.Help me care for myself.Help me manage my medications.Help me manage my appointments.Help my family caregivers help me.Help me connect with other Veterans.Make it easy for me to send you information.Let me share my information outside the VA.

Voice of the Veteran: What They Want…

It’s a good time to re-design our work.

e-Patient Dave:“Let Patients Help”

Participatory Design

Informed Patient

Patient Centered Teams

Participatory Care

Toward patient participation

“As younger generations embrace technology, one of the oldest tools in medicine, the doctor’s note, is in its

infancy of reform.”

TW Feeley and KI Shine, Annals of Internal Medicine, 2011

Talk to Patients. They Know Cool Stuff You Don’t.