Patient Engagement Via PHR: Cleveland Clinic's Bold Initiative

Jan. 14, 2014
Lori Posk, M.D. is a practicing internal medicine physician and the medical director of MyChart, the personal patient portal at the Cleveland Clinic, the integrated health system in northern Ohio. Dr. Posk and her team have been helping to lead a successful initiative that has been bringing more and more automated release of EHR information directly to patients.

Lori Posk, M.D. is a practicing internal medicine physician and the medical director of MyChart, the personal patient portal at the Cleveland Clinic, the integrated health system in northern Ohio that encompasses 10 owned hospitals and one affiliate hospital, with 4,450 beds, more than 75 outpatient locations, and more than 3,000 physicians and scientists, and which serves 5.1 million patients a year.

Posk, who was a full-time practicing internist, in May 2012 became medical director of MyChart, which uses the MyChart personal health record (PHR) capabilities of the core electronic health record (EHR) solution from the Verona, Wis.-based Epic Systems Corporation. Beginning embryonically in 2002, and more robustly since 2005, leaders at Cleveland Clinic have been enabling multiple capabilities for patient-provider and provider-patient communications and patient engagement, crescendoing up to the automated release of most ambulatory care physician notes to the MyChart solution late in 2013.

Posk, who works with a team of eight people, including system analysts and clinical analysts, managing MyChart on a daily basis, also interacts regularly with a multidisciplinary oversight committee called the MyChart Physician Advisory Group, which provides ongoing advisement for the initiative, and which has functioned both as a sounding board and a bridge to physicians and other clinicians and healthcare professionals across the very large Cleveland Clinic organization, to provide input and feedback for ongoing development.

Posk is speaking about Cleveland Clinic’s initiative at the upcoming Health IT Summit to be held January 21-22 in San Diego, sponsored by the Institute for Health Technology Transformation (iHT2). The Institute became a part of Vendome Group, LLC, Healthcare Informatics’ parent company, in December 2013. Posk spoke recently with HCI Editor-in-Chief Mark Hagland about the MyChart initiative and Cleveland Clinic and its implications for patient engagement and other areas in healthcare. Below are excerpts from that interview.

This is quite a broad initiative in certain respects. You have an advisory group called the MyChart Physician Advisory Group, but it is actually multidisciplinary, correct?

Yes. We do have representation on the committee from nursing, social work, physical therapy, nutrition, legal, health information management, the privacy office, and others, on the committee. Looking back now, we probably should have begun with a broader name for the group, as the name is a bit of a misnomer. But yes, it is multidisciplinary, and the 25 or so members really do represent a broad spectrum of leadership at Cleveland Clinic.

Lori Posk, M.D.

What are the basic features and functionalities of MyChart?

Starting in 2009, we started sending lab results to patients. There wasn’t a lot in MyChart before that; providers could manually release information to it, but this was the first type of automated release. So we started on this journey, in 2009, to work towards a more engaged and active patient. So in October 2012, we started with automating the release to patients of the reports for x-rays—standard plain film x-rays of the chest, limbs, etc. There’s a purposeful three-business-day delay built into the process, so that if an x-ray result comes in, the result will automatically be sent to MyChart for the patient to be able to view it, after two business days. And in April 2013, we ramped it up some, and expanded the automated release to additional imaging studies, including CT, MRI, bone density, nuclear studies, and ultrasound; in all cases, this is the release of the radiologists’ reports.

How many data releases a month are involved?

Between January 2013 and September 2013, we had 3.5 million test results released, including lab results and imaging reports, and more. In June 2013, we started releasing pathology reports. Physicians’ concern was, of course, if you start releasing pathology reports, can patients understand them? In July 2013, we started releasing procedures, such as cardiac stress tests, colonoscopies, and EGDs; so the 3.5 million test results released statistic for that time period encompasses all of those items.

And the advisory committee approves all new additional types of releases, then, correct?

Yes, really, the group is used to let us sort through clinician concerns with. I’m an internist and work out of a regional office at Cleveland Clinic, so what I think makes sense may not make sense to a cardiologist working on the main campus. So we use them as a sounding board. And we have definitely incorporated their feedback into our planning and development. The most obvious way in which we’ve done so has been to incorporate timed delays into the automated-release processes. So  lab results are released into MyChart using a two-business-day delay; plain x-ray radiologist reports are released based on a three-business-day delay; for additional imaging reports, we inserted a 10-business-day delay. But the provider can manually release the information into MyChart at any time sooner than those automated timed delays.

We received a lot of input from pathologists and oncologists on the subject of releasing pathology reports into MyChart, and those specialists insisted on a 20-day delay on pathology report automated release. The patient may need to be brought back into the physician office, or additional pathology markers may need to be added. And it was an insight on my part as a primary care physician, to receive that kind of feedback from the specialists.

And then, starting in September, we started releasing the patient’s problem list automatically to MyChart, so whether you have schizophrenic disorder or hypertension, it’s released. And our big finale for the year was our physician notes release. And the Open Notes Study had created a lot of good study for this. We started releasing physician ambulatory notes on November 19.

That’s rather a big deal.

Yes, it was a big deal, let me tell you! And a lot of providers have had a lot of concerns.

So what has happened, per those physician and other provider concerns?

Not a lot, which is good news. We’ve had close to 100,000 notes released. And one important aspect of this that I should note is that providers can make the choice, should they be documenting something that they think might potentially be harmful for patients to see, they have the opportunity to document what’s called a “sensitive note” in the EHR. We didn’t put any specific criteria around what would constitute “sensitive,” but we’ve found that the sensitive-note function is only being used by the physicians 2 percent of the time. In that context, it’s also important to note we’ve blocked behavioral health notes, including psychiatry and psychology notes, and notes for adolescents ages 13-18. And once again, with regard to giving providers the sensitive-note option, this was an example of the result of feedback from our multidisciplinary advisory group.

Have there been any technical challenges in this initiative?

The analysts could say more about that, but not significantly. The real challenge is that we’re such a big organization, so trying to get an understanding of how people document and where they document. We were ready to go live with patient notes, but we found that our regional hospitals were documenting differently from our central campus, so we held off on that. We’ll probably release inpatient notes later this year. But this whole initiative of increasing patient data release was something that Dr. Cosgrove [Toby Cosgrove, M.D., Cleveland Clinic’s CEO] was spearheading.

So he and the senior executive leadership team are behind this?

Yes, they absolutely are.

Have there been any other challenges?

The rest of the challenges really were around managing the fears of providers. I got involved because I manage MyChart, but also see patients half-time. And my main goal as a clinician was to find out how I could optimally run my office and also improve patient care in my office; so I got involved in the broader transparency project at Cleveland Clinic to help improve quality. And prior to getting involved, I was very resistant, and thought it would be an awful thing to share all this information with my patients. But I did a 180-degree turn on that, as I got involved in this. In fact, I’ve found that, when patients were calling about something that they saw on MyChart, and they were raising question to me, I thought that was a good thing. Now, not all providers feel as I do; but they’re finding out, to their relief, that the release of information into MyChart has not resulted in one of their biggest concerns, which was that their offices would be flooded every day by calls from patients focusing on incidental elements that are not clinically significant. That issue was the biggest concern on the part of providers, and it’s been solved.

So you would agree, then, on the importance of pursuing this path, with regard to accelerating patient engagement?

Yes, I believe that partnering more with our patients to get involved with their care will only lead to better quality and outcomes. And I can say that my perceptions have for the most part been validated; the world has not fallen down.

Another benefit here is that, obviously, what you and your colleagues have been doing fulfills requirements under the meaningful use program as well, correct?

Yes, and clearly, we’re definitely going beyond fulfilling those requirements. And also, we’ve initiated patient messaging through MyChart. Patients can initiate a message through MyChart to their provider. We started with a pilot on that in my office in 2012, not realizing it would be a requirement under meaningful use. And then we rolled it out to the rest of our regional medical practices for internal medicine, family practice, and pediatrics, throughout the year 2013. We didn’t do a big bang; we’ve gone from large family health center to family health center working with the physicians and staffs on this, in a rolling pattern. And in the first quarter, we’re going to do this with specialists. And ideally, by the end of the first quarter, patients will be able to message their providers for non-urgent matters. And they can do it on their desktop computers, or in our app for Android and iPhone.

You had to develop those?

This is actually an Epic MyChart function. The good and bad of it is, it does limit us some, but at least patients can get refills that way, can message us, and can see their test results, so it allows us the Epic functionality.

Do you have any explicit advice for our audience?

One thing that, if I had to do it again, I would do over differently, is this: for a lot of these test result releases, I would just have gone live with all of them at once. And I’d just have one timeframe for release, not 3-day, 10-day, 20-day; I’d push for more standardization of the time-delay processes. But we’re hoping to get at a much shorter-time release, but we wanted to get our providers comfortable. So we initially started with a 5-day release for lab results, but waited about 18 months to go to the 2-day standard; we wanted to get physician feedback on that. But I am very grateful for the input and feedback from physicians and clinicians in practice, all along, in this process.

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