Change doctors’ minds on OpenNotes in about an hour

My prediction for 2014 is that it’ll be a blockbuster year for OpenNotes – sharing clinical notes with patients online.

For providers who want that level of transparency, yet find physician attitudes can be a roadblock – take heart. We can move the needle and change minds. I observed this during Medicine Grand Rounds at Oregon Health & Science University (OHSU).

Tom Yackel, MD, MPH, OHSU’s Chief Medical Information Officer invited me to join him to give a talk on OpenNotes. It was a easy ask; I’m a huge champion of the Veterans Health Administration’s Blue Button offering OpenNotes, now one year and counting. Sharing notes is also an area of my research, particularly from the perspective of patients and caregivers.

Grand Rounds was just before the holidays, so I worried about attendance. Turns out it was well attended. Maybe the topic raised curiosity. We gave out audience response gadgets to poll attendees at the beginning and end of the talk. Early on, we asked people their agreement with the question, “I think sharing progress notes with patients in MyChart is a good idea”. Purposely not displaying results the first time, we asked again after the presentation & discussion. The proportion who agreed sharing notes was a good idea increased from 54% to 80%.

It’s hard to know if the patient experience stories hit home, or maybe people were leaning to support OpenNotes in the first place. Perhaps a crucial moment happened when the discussion focused on provider workload and a physician leader said:

“We’ve been doing this for 10 years at the VA, and I’ve never had any problems from a patient being able to read their notes. We need to get over this and move on.”

Here’s our results — Before and After Grand Rounds:
DMICE Grand rounds 2013

When it comes to OpenNotes, engagement with Patients starts by Engaging with Providers. Yes! We Can!

Link to Grand Rounds video is here.

Here are the slides we presented:

What part of Patient Centered Care do medical guilds not understand?

Update: Two days after the NY Times story, the American Board of OB/Gyn modified their rules allowing members to treat men for STDs and screen for anal cancer. That’s Patient Centered (and member centered)!

I try to stay positive. My dear colleague Ted Eytan says he’s “3/4 full” – I love that. Staying positive in health care can be a hard these days. Here’s an oxymoron for today: Patient-Centered Organized Medicine.

Patient centered they’re not, says the New York Times today, in Gynecologists Run Afoul of Panel When Patient Is Male, a story about Boston’s Dr. Elizabeth Stier. It seems that in her Gynecology practice she sees some men at high risk for anal cancer. She sees the condition to mirror cervical health in women, and she’s become a local expert and valuable resource to her largely low income male patients. But the OB/Gyn board drew a line and said if she treats men, she loses her specialty certification.

A quick look at the OB/Gyn Board website, and I wonder how much they know their members, or know the patients of their members. The Executive Team is all men. Of 15 Board of Directors, 10 are men. I’m not saying gynecologists must be women, but I wonder: how Patient Centered is this specialty organization? How participatory is their decision-making?

I’m reminded of a 2007 paper by Hal Sox, Medical professionalism and the parable of the craft guilds. He wrote about how important it is for medical societies (a contemporary version of craft guilds) need to put patients at a higher level than self-interested and adopt a broader code of professionalism, stating

While meeting the needs of individual patients, physicians are required to provide health care that is based on the wise and cost-effective management of limited clinical resources.

My understanding of Patient Centered is changing, coming to be more about equal footing and a balanced distribution of power. Speeches like the one Anna Quindlen gave at the American Association of Medical Colleges, AAMC, are extraordinary and illuminate rigid, problematic mindsets today. Quindlen, prize-winning author, shared her stories with med school deans and leaders about how health professionals seem to sometimes not know their patients – leading to poor quality and experiences. What is it about Patient Centered Care that medicine doesn’t get? The irony is ridiculous: we’re too busy taking care of patients. Appointments, schedules, electronic records, pagers, phone calls, faxes, secure emails, quality measurement, performance pay, and…and…

Her speech is only available until December 3rd, posted here. (posted about this on the Society of Participatory Medicine blog)

Whether it’s about learning more about individual patients’ values and needs, or the needs of the health professionals who work hard getting to know and care for their patients — it’s where we need to move. About that, I’m Positively 4/4 Full.

We Must Have Patients and Caregivers Shaping Medical Curriculum

Many years ago, I sat through 2 years of lectures in medical school. Then, 2 years in the hospital. Then residency and clinics, hospital wards and more wards. How patients were viewed was always the same. They were there to answer questions, put up with exams, a lot of testing and feeling poorly. Writing of notes was endless, as were lists of possible diagnoses, test ordering and treatments.

At no time, and in no venue, did anyone consider patient as teacher. It was never conveyed that ‘patients were the experts of their issues’.

Such a lost opportunity. Maybe, just maybe, healthcare is waking up.

Pt Educ Counsel
A wonderful paper in
Patient Education and Counseling, What parents want from emails with their pediatrician: Implications for teaching communication skills is well worth a careful read. I believe it’s an important step and signal for the future. It’s a great example of Participatory Design, having patients and caregivers contribute to improvement of the health care system.
Schiller et al.

Researchers and educators in Ann Arbor, led by author Jocelyn Schiller, asked parents to read and review secure email messages between parents and medical students during their pediatrics clinical rotation.

Pediatrics faculty created ‘simulated messages’, or hypothetical messages from parents of pediatric patients. The medical students were asked to reply to the secure emails. Parents were then asked to read and comment on the messages. Finally, the parents comments were compared to the assessments done by the Pediatrics faculty.

The results were not surprising, but have significant implications for teaching medical students (or any health professional trainee) about communication. Parents were pleased when students provided information in a clear manner, with specifics on what to expect or ‘next steps’. Parents, however, gave lower scores than faculty for students’ ability to show empathy or show respect. The authors state,

…there may be subtleties in expressing empathy and respect that are acceptable to faculty and medical students, but that communicate negative connotations to patients and parents. These differences may be exacerbated in written communication.

The researchers remark that patients and caregivers are an important stakeholder in curricular reform, offering a different perspective from health professionals that enhances communication skills education.

The paper is a key contribution to Participatory Medicine. Patient advocates and participatory clinicians see this as necessary direction — getting patient voice into medical training. This needs to go even further than what this study accomplished; parents and patients directly involved in educational sessions, not just giving feedback on paper. After reading this work, the services of patient advocates just got better defined.