Tom Deblanco: maximising patient engagement

July, 2015 - Pennyhill Park, England

Improving the Quality of and Efficiency of Health Commonwealth Fund-Nuffield Trust

Using Health Information Technology to Maximize Patient Engagement:

Early experience with fully transparent medical records in the USA

Tom Delbanco, MD, MACP, Koplow–Tullis Professor of Medicine, Harvard Medical School

Beth Israel Deaconess Medical Center

What are open notes?

Open notes are visit notes that patients can access online

through patient Internet portals.

www.myopennotes.org

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1-year Demonstration Project summer 2010 – summer 2011 (and still ongoing)

Patients invited to view their primary care doctors’ signed notes

via secure portals (only notes signed during the project – not retroactive)

Each patient notified automatically via secure e-mail message when a note was signed, and later reminded to review note(s) before next visit

Patients and doctors completed surveys before and after, and we

collected administrative data (portal clicks, e-mail volume)

Primarily funded by the Robert Wood Johnson Foundation

About the OpenNotes Study

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Three Principal Questions

Would OpenNotes help patients become more engaged in their care?

Would OpenNotes be the straw that breaks the doctor’s back?

After 1 year, would patients and doctors want to continue?


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108 volunteer PCPs and more than 19,000 of their patients who use portals:

• BIDMC (urban and suburban Boston) 39 PCPs & 10,300 patients

• Geisinger Health System (rural Pennsylvania) 24 PCPs & 8,700 patients

• Harborview Medical Center (inner city Seattle) 45 PCPs & 270 patients (new portal)


Diverse Sites

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Patients’ Experience

82% of patients opened at least one of their notes…and they continue to read them

Including patients who were older, sicker, less educated

Few patients said reading notes made them feel

Worried (5-8%)

Confused (2-8%)

Offended (1-2%)

20-42% of patients reported sharing notes with others

Among Patients with Notes (Visits)


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About 3 out of 4 patients reported:

taking better care of themselves understanding their health and medical conditions

better feeling more in control of their care feeling better prepared for visits doing better with taking their medications as

prescribed (a very big deal…)

Reports from Patients


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After one year, 99% of patients

wanted to continue to be able to

see their visit notes online..

When given a choice of doctors or health plans in the future:

4 out of 5 patients said availability of open notes would impact their

choice of provider.

The Bottom Line for Patients


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Doctors’ Concerns and Experiences

About 50% expected disruptions in workflow.

A year later…

Only 3% reported longer visits, or answering more questions afterwards

They expected to change writing about mental health (43%) substance abuse (38%) and cancer (27%)

About 25% said they were changing the way they wrote notes ..

About the OpenNotes Study About the OpenNotes Study

They were scared…

My fears: Longer notes, more questions, and messages from patients. In reality, it was not a big deal.

I felt like my care was safer, as I knew that patients would be able to update me if I didn't get it right.

I felt great about partnering with my patients, and the increased openness.

Patients should not have access to their notes. The note already serves far too many purposes such as billing, research, etc, and adding one more is not a good idea. They are not intended as a vehicle for patient communication.


Comments from Doctors

After a year, PCPs were asked:

Taking all considerations into account,

I would like my patients to continue

to be able to see my visit notes online.

At least 3 out of 4 said YES, and

even though some said NO,

At the end of the trial, not one doctor asked to turn it off for their patients.


The Bottom Line for the doctors

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All 3 sites decided to expand OpenNotes

Geisinger : 1,400 ambulatory doctors/NPs/PAs, and 200,000 patients Harborview: all UW primary and specialty

clinics, doctors/NPs/PAs

BIDMC: All clinicians’notes,

vast majority of ambulatory clinicians


The Bottom Line for the Three Institutions

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A New Medicine that brings benefits…

and risks

A catalyst for change…and not only

in ambulatory care Patient Safety

About the OpenNotes Study About OpenNotes

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About OpenNotes

Might open notes… (the good, bad, and the ugly)

Bolster adherence: to preventive measures, referrals, treatment plans?

Bolster adherence to medicines?????

Diminish redundant test ordering?

Identify mistakes (commission and omission)?

Affect missed appointments, visit rates?

Help move care into the home?

Motivate us to write differently? For whom?

Affect patient and provider trust (in a litigious society)?

About OpenNotes


Lead patients to hide important information?

Expose the perverse incentives of RVUs…(a question peculiar to the USA)?

Get providers to sell rather than…?

Harm some patients, at times badly?

Put (justified) plaintiffs at risk in court?

Herald the start of an onslaught from patients and their families?

About OpenNotes


About OpenNotes

Caregivers

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Medical education

About OpenNotes

20

Mental health

About OpenNotes

21

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1 of 3 patients wanted to be able to approve what is written in a note

3 of 5 patients wanted the ability to add comments to their notes

About OpenNotes Looking ahead

Clues from the OpenNotes study

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Patient

Plans

Clinician

Looking ahead Looking ahead

Next: OurNotes

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Looking ahead Let’s discuss…

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26

27

% who think Nonparticipating

PCPs (%)

Participating

PCPs (%)

Patients

(%)

Open notes is a good idea

Patients will better

understand their health and

medical conditions

Patients will worry more

Patients will find notes more

confusing than helpful

25

53

90

76

95

92

14

11

76

85

51

48


PCPs’ Main Concerns

OpenNotes Impact on Workflow

Pre-intervention (%)

Post-intervention (%)

More time addressing patient questions outside of visits

42

More time writing/editing notes

39 11

3

Email message volume did not change



29

Changes in documentation

Changed the way they

addressed:

Pre-intervention

(%)

Post-intervention

(%)

Cancer/possibility of

cancer 27

Mental health issues

43

Substance abuse

38

Overweight/obesity

19

15

24

19

16



Health & Medicine

Tom Deblanco: maximising patient engagement