Tag Archives: clinician

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:

Doctors on Open Notes: “It was easier than expected”.

Open Notes Investigators Suzanne Leveille, Jan Walker & Tom Delbanco at Beth Israel Deaconess in Boston

We’ll look back on this day as a historic turning point in the transparency of medical records, moving toward fully sharing notes with patients. Open Notes, a research study at 3 large medical systems, shared their results. Findings are momentous: a WIN for patients and a NO LOSE for providers.

It’s been 40 years since Shenkin and Warner predicted, in the New England Journal of Medicine, that patients given “complete and unexpurgated copy of all medical records, both inpatient and outpatient” would enhance patient autonomy, improve patient-physician relationships, and serve as an educational tool (no access to this 1973 paper!). With Open Notes, we have substantial evidence that patients benefit and clinical fallout doesn’t happen.

Congratulations to Tom Delbanco, Jan Walker and colleagues for their dedication and effort to pull off a 3-site study. Among over 13,000 patients, almost all opened their notes at 2 sites and half did so at 1 site. Patients better understood their health condition, were more prepared for visits and felt more in control of their care. Patient activation happens. Providers, many who were skeptical about patient benefits, continued to underestimate these benefits even after 1 year. Why? Because they didn’t know when patients were reading their notes! Only 1 out of 5 patients talked to their doctors about the notes! Most importantly, providers were less likely to say their work increased. The authors even looked at secure email volume before and after: no change.

So, it’s a no brainer for patients. But for providers, too. Some favorite quotes from the paper:

When asked about the most difficult aspect of open notes, the most common comment among the 77 out of 104 responding PCPs was that nothing was difficult and that they experienced no changes in their practice.

Although several doctors acknowledged fears about additional time burden and offending or worrying patients, they wrote that these concerns did not materialize. Some commented on the extra time needed for writing, editing or explaining notes to patients. Among them, some framed such efforts as learning ‘better documentation – a good thing.’

In a post 2 years ago, I thought Open Notes would be a Slam Dunk. How my predictions fared, based on Open Notes results:

1. Once patients see their notes, they like access. 99% want to continue.
2. Medical jargon doesn’t get in their way. >90% were NOT confused or worried.
3. Some content surprises but people value it. PENDING study of patient comments.
4. Many say notes are wrong and want corrections. 60% want to add comments.
5. Seeing notes helps manage problems better. >70% reported better self-care.
6. It’s uncommon for a person to be distraught. Only 1-2% felt offended.
7. Many feel more prepared for in-person visits. 69%-80% agreed.

I’ve been studying open notes at the Veterans Health Administration for the past few years. The first version of the My HealtheVet PHR gave patients access to all notes. My research team and I just submitted our results for peer review; our findings fully support and complement the Open Notes study. It’s a really exciting time for participatory medicine, re-designing health records, and the journey toward open notes for Veterans & family by expanding Blue Button. Let’s get going: it’s gonna be awesome.

The Health Care Blog: Robert Wood Johnson Foundation’s Steve Downs – Open Notes Results Are In
ePatients.net/Society for Participatory Medicine: OpenNotes: The results are in. GREAT news for patient engagement.
Ted Eytan: Open Notes results are in…

Dumb patients? No way. It’s only normal behavior and status-quo clinical care.

A recent CNN story, 10 dumb things you do in the doc’s office, has caused a lot of discussion on ePatients.net

I agree with much of the discussion, but I take issue with parts of the article. First, patients aren’t dumb. This stuff happens, for lots of reasons. Not enough time. Fear of disclosure. Forgetfulness. Stress. Paternalism. OMG. If people never do these things during a doctor visit, it’s a miracle. Second, there is no instruction manual on “being a patient”, often stated by Jesse Gruman. It’s not intuitive to figure out how to make the most out of visits. Third, clinician communication training is, er, not done (or not done well). I was lucky. I did general medicine training in the 1980’s; we had a psychologist on faculty (Rhode Island Hospital), and her job was to hone our communication skills. How many residents have this training? Even if they do, skills degrade rapidly with lack of sleep and doctor-centric care…so it’s a constant struggle to maintain. Finally, there is no incentive to talk well. Pay-for-performance is about tests and more tests. Electronic records remind us to do things, but I’ve never seen a computer pop-up about asking a patient, What’s on your mind?

I’m glad that article was written, because things need to change. But it has to come from all sides. Patients/consumers/families need coaching about how to engage more and articulate their needs. Docs and all health professionals must learn how to foster that engagement. It requires a different kind of philosophy about care. It’s a conversation, a dance, a style. Now that we’ve done well on the science of medicine, it’s time to get back to the art of medicine.

So I’ll modify 10 things patients do…and suggest some art (“Hey Doc”):

1. You talk on your cell phone.

Instead: How important is your time? Stop multi-tasking. Focus. Would you talk on your phone during a conference with your kid’s teacher? Your car mechanic?

Hey Doc: If your patient isn’t paying attention, figure out why. If it’s not possible, validate that other things are on their mind. Suggest another appointment, a follow-up call or secure email. You’re the doctor. Diagnose multi-tasking (and, by the way, even though you think you can do it, you can’t).

2. You lie.

Instead: You have the right to not share things. If you decide to hold back, make sure it’s for a good reason. Ask yourself why you don’t want to share. Are you afraid you’ll be judged? Lectured at? If so, say someting like “I want to tell you something, but I’m not sure how you’ll respond.” That’s a signal for the doc to listen and not react. If they behave badly, vote with your feet.

Hey doc: It’s your job to make people comfortable so they share their stories. People have a right to not disclose, but if you build trust then sharing happens. Listen and don’t interrupt unless it’s necessary, and make the visit about the patient’s agenda. If you find discrepencies in a patient’s story from one visit to the next, get over it. We tell different stories about ourselves all the time.

3. You do a sloppy job describing your pain.

Instead: If you have pain, help your doc figure out what the problem is. Pain is complicated, and it’s not easy to figure out what it’s from. The doc is wondering if it’s nothing to worry about or it’s serious. They don’t have the pain, you do, so you’ll have to describe it as best you can. If you don’t understand a question, say that. If you’re having a hard time answering, say that.

Hey doc: You’re the diagnostician, you figure it out. Ask relevant questions. Ask the same question different ways. Ask a family member. Don’t make it the patient’s job to answer questions “the right way”. Don’t forget to ask, What do you think it is? The answer might surprise you.

4. You don’t state up front all the reasons for your visit.

Instead: Prepare for your visit. Write it down! Send yourself a text message! This goes with #1 – use your time wisely, your time is precious.

Hey doc: Ask, What else? Then ask it again. If it’s chest pain – deal with it. If it’s knee pain present for 5 years and you’re 45 minutes behind, make a plan to address it. Use secure email for goodness sake and have a team-based approach to communicate between visits. Orient your patients to how to communicate with your office, and do it all over again when they need it.

5. You don’t state up front your expectations for your visit.

Instead: Prepare. What do you really want to get out of the visit? Write it down. An explanation of what’s wrong? To be reassured nothing bad is going on? To make sure all your preventive care is up to date? To say the medicine you tried didn’t work, and gave you side effects? To tell about stress, and how it’s affecting your work or your love life? Be honest with yourself, and take control of the visit. If you think your list annoys the doctor then say, Is there a problem with me having a list? I use it to make sure I don’t forget anything.

Hey Doc: This is medicine 101 – ask up front what someone wants to talk about. Back to #4, ask What else? Doing this may seem to make the visit longer but it doesn’t. It’s OK to have your agenda, like that daily alcohol…but their agenda comes first. Do you need research on this? It’s there: more trust, better outcomes, higher patient satisfaction with you.

6. You don’t know what medications you’re taking.

Instead: You are the only one who knows what you’re doing with your health. Taking medications is a big one. This goes with #2, about sharing your story. If you have a hard time remembering to take your medicine three times a day, share that. If you can’t afford it, say that. If you have side effects, let the doc know. Ask about alternatives. There might be something easier to do. Do you understand why you have to take all those medicines? Ask. In the end, it’s up to you to make choices about what to take and how to take it.

Hey Doc: How do you spell Medication R-E-C-O-N-C-I-L-I-A-T-I-O-N? What does reconciliation mean? To make compatible or consistent. It’s part of your job description. The first step is to identify reality – figure out what a patient is actually doing with their medications. Then reconcile this with your recommendations. This is where it gets really fun: figure it out together!

7. You leave with unspoken questions and concerns.

Instead: Don’t leave questions unanswered. Do your own research, but balance getting information on your own with information from a health professional. Figure out how to get care between visits. Ask the doc if they use secure messaging (not insecure) so if you have additional (non-urgent) questions, you can send one in at 3 AM. Ask what number to call to talk to the nurse, the doc, to anyone. Put in on your phone and stick it in your wallet.

Hey Doc: Provide access to you and your team between visits. Enough said.

8. You don’t bring your medical records or images with you.

Instead: If you get care at multiple sites, don’t assume they have all your information. YOU are the best record-holder, so sign those forms called “Release of Information” and get copies yourself. Read the records, and make sure they’re accurate and complete. Ask if there’s access to records through the Internet. If so, sign up today.

Hey Doc: Find out about other providers and tests and have a complete record. Offer a patient portal and share information electronically. Print out copies of results or progress notes so they can take it with them to other providers.

9. You’re too scared to disagree with your doctor.

Instead: If you don’t agree with your doc, say so, without arguing. There’s not much else to say about this. Insurance companies may pay for a second opinion.

Hey Doc: You’re not responsible for your patients, you’re responsible to them. An engaged patient asks questions, looks for answers, weighs information they get on their own with information from experts. They work to identify all options and make decisions. Embrace this, because it makes for a better interaction and happier patients.

10. You don’t comply with the treatment plan.

Instead: What is the treatment plan? What are the options? Make sure you know what they are, and why they are recommended. Figure out what is realistic for you. Maybe you want to do it, but have a hard time. Maybe you need to take smaller steps. Maybe you don’t agree with the plan. Be honest with yourself and then be honest with your doc.

Hey Doc: Learn how to do shared decision making. It’s all the rage.