As the OpenNotes movement, in which physicians and patient care organizations are sharing physician notes with patients following their doctor visits, moves ahead, the medical informaticists in patient care organizations across the U.S. are figuring out ways to help lead change among their fellow physicians. That is one element that was discussed by a variety of clinical and clinical informaticist leaders across the U.S. healthcare system, with the broad spectrum of advancement in this key area the subject of the July/August Healthcare Informatics cover story.
Among the medical informaticists interviewed for that cover story was Allison Weathers, M.D., associate CMIO at Rush University Medical Center, an academic medical center in downtown Chicago. Weathers, a practicing neurologist, believes it is very important for specialists to consider how valuable opening their notes to patients can be for their practices as well—not just the practices of primary care physicians. Below are excerpts from HCI Editor-in-Chief Mark Hagland’s interview with Dr. Weathers from earlier this summer.
So much attention has been paid to the value of OpenNotes in the sphere of primary care practice. But opening physician notes to patients can prove very valuable in the specialty care practice as well, correct?
Yes, that’s right. And this is one of the areas I’m really passionate about, the power that OpenNotes has to drive patient engagement. Everyone has this vision of what old-school neurology is like, but it’s totally different now. There’s this quote that patient engagement is the blockbuster drug of the 21st century—Dr. Leonard Kish—I think it’s a great quote. So I was a huge proponent of the patient portals here at Rush. I led a lot of the education for providers. Because everybody knows how to click at this point. So what does it mean to have patients messaging you, and so forth? That was our horizon in this area.
And in the case of Rush University Medical Center, you were handed a bit of a timely opportunity as well, right?
Yes, that’s right. We were planning for an upgrade of our Epic EHR [electronic health record] in February of this year, anyway. It was a massive double upgrade from the version of Epic we had been on, and Epic was going to look and feel different anyway. So I said, this is a great opportunity; I have to get up in front of everybody to explain changes anyway, so why don’t we do this? So we got buy-in from hospital leadership and from the medical directors. And the bottom line is that this is the patient’s legal right to this information. Patients could get off a call and call health information management and get their legal record, anyway.
So what we chose to do was, for every next ambulatory visit from go-live, from February 8 on, all ambulatory notes as a default, were going to be released. However, at the individual note level, you always have the option to opt out. It’s a big blue box at the top of your screen. So if it’s going to be unduly upsetting or otherwise problematic, you can always choose to unshare the note. The data for mental health providers isn’t quite as strong yet, so for our psychologists and psychiatrists, their box is by default unchecked. So they have to go in and manually unclick it.
You’ve been in your position since January 2013, and have been working closely with Brian Patty, M.D., your organization’s CMIO, on all this, correct? And you’re also still practicing clinically part-time?
Yes, that’s correct. I always joke that Brian is kind of the vision and strategy guy, and I’m kind of the person in the weeds, working with the physicians. So it’s important for me to continue to practice, for that position. I’m an academic general neurologist; and I’m spending half of my time in clinical practice and half of my time in medical informatics.
It seems obvious to me that we need more specialists who are functioning as medical informaticists in patient care organizations, for so many reasons.
Yes. And it’s interesting, a lot of medical informaticists do come up through ED or primary care. But yes, it’s nice that I’ve been able to do that. Initially when I got involved, there weren’t that many neurologists who were involved. So I’ve gotten really involved with Epic, and I’m helping them to make their build better for neurologists, and with the American Academy of Neurology.
How many years have you been involved in informatics in some way?
I really began when I was still a fellow. The CMIO of Rush at the time needed someone to be a liaison to house staff, so I essentially became that liaison to our house staff, back in 2007.
Do you have any metrics yet on some of this advancement?
As of [April], over 83,000 notes had been shared. However, only about 33,000 of those notes were for MyChart-active patients. And only about 185 have actually been viewed, because we did this as a soft rollout. We said, we’re going to keep this quiet at the beginning, to make sure the doctors weren’t coming at me with pitchforks. Because the fear is that patients will call when the grammar is wrong or they don’t understand a word. But the studies have shown that that’s not true, they go to Google for that.
And we recently went back to the heads of the medical practices with request for feedback. They told us that everything was turning out just fine. In fact, we’ve heard very little negative feedback. Instead, what we got for the heads of the practices was basically a bunch of shrugs. Meanwhile, this can be so meaningful for patients. So I said, “game on.” And I went back to our marketing department, and said, “Look at this cool thing” [the soft rollout of OpenNotes]. So Marketing is preparing a story about this, to be published soon in our patient-facing publication. And to my knowledge, we are the only hospital in Illinois that has so far done this.
Altogether, how many physicians are involved in this so far?
It’s a couple of hundred. Right now it’s our Rush University Medical Group, and plus some of our affiliated practices, such as Rush Oak Park Physicians Group, as well as a few scattered other providers.
When might this initiative move into the inpatient sphere?
I’m aware that there are some pilot sites around the country that are experimenting with this on an inpatient basis, but it’s not as widespread yet in inpatient. There are issues with copying and pasting. That’s much more of an issue on the inpatient side; there are more limitations. I’d love to get there, and some hospitals starting to move closer to that reality.
What’s your assessment of the OpenNotes movement so far?
I think it’s working very well. And with regard to workflow and related issues, it’s turned out to be a non-issue among providers [physicians]. It’s not creating more work for us, we haven’t gotten more phone calls. I had a conversation with a patient the other day; I was giving her complicated instructions, and I told her about this, and she said, oh, that’s really great. She’s a very intelligent woman, she was about to go into surgery. And it was really an amazing thing for her to go back and have that as a reference.
And if you look at some of the quotes that have come out per these studies, even patients feel it helps to hold them accountable. It’s a partnership. At the end of the day, it has to make sense for them. But sometimes, being able to go back after the fact and read why I made a recommendation, sometimes that helps the patients. And two, it holds them accountable. Like when the patient says, oh yeah, my doctor told me to quit smoking. When they see it written, it holds a different weight.
Were some of the specialists at Rush perhaps a little bit more frightened than some of the PCPs?
Yes, I think there was some concern. But we decided to try to allay those concerns as much as possible. And that was my other thing: for a hospital that touts who innovative we are, how much we’re on the cutting edge. And other hospitals have been doing this for five years now. And how do we say we’re on the cutting edge if we’re not even making information available to patients, that’s their legal right?
And I’m working on a project with the American Academy of Neurology, we’re putting together a toolkit for neurologists on this topic. What are the things to look out for? And a lot of times, patients come in with symptoms, we don’t yet have a diagnosis. Or sometimes, with a diagnosis, we’re not finding a physiologic cause and we might feel that stress might play a role, and how do we get that out there? And I’m working with two other neurologists as well as the CMO, another neurologist, of a neurology practice, as well. Two doctors are in Texas, and one in California, and me.
When will your toolkit be ready?
Hopefully, the basic toolkit will be out soon. The paper, we’re hoping to have that submitted in the next few months.
What have been your and your colleagues’ biggest lessons learned around all this so far, and what would your advice to CMIOs and CIOs be, based on that?
I’m going to steal the quotes of the teams who went before us. There’s a lot of angst, a lot of fear, over what turns out to be the biggest non-issue for providers. So you just need to get in there. I try to work very closely in partnership with providers. At some point, though, we know this is the right thing to do. And you’ve got to move forward. And we could still be focus-group-ing and committee-ing around this. And that can be important, but we just had to move forward with it. It’s the right thing to do for patients.
I think one key element in our case was that I went in prepared when I presented on this opportunity. I had my data, I had my PowerPoint; and I had support from other clinician leaders. I had one of our vice-presidents, a physician leader over the medical group, and other support. It wasn’t like IT was driving this one.
And that’s important, too, correct?
Yes, that’s critical that it not be an IT thing. If I hadn’t gotten his support, I couldn’t do it. And I had the support of the physician leader at Rush Oak Park as well.
