UCHealth, based in Aurora, Colo., has given patients online access to the clinical notes physicians write at its five hospitals and 350 clinics. However, it hasn’t been an easy path to becoming a transparent healthcare organization, according to C.T. Lin, MD, UCHealth’s chief medical information officer.
UCHealth is part of a growing nationwide movement among providers—called OpenNotes—designed to enhance patient-physician communication by sharing clinicians’ notes with patients and to make their medical records fully transparent. The goal is to bolster overall safety and quality of care by ensuring the accuracy of clinician note-taking, while reducing medical errors and improving medication adherence.
Lin contends that UCHealth is the only provider of OpenNotes in the state of Colorado, and boasts that it is the health system that has adopted the concept more broadly than any other in the country. Last year, he says that the healthcare organization “turned on” OpenNotes for all of UCHealth’s medical and surgical specialties, primary care practices, as well as hospital discharges.
“We have on the order of 70,000 hospital discharges per year, so every patient’s discharge summary written by a doctor is available to them on the portal,” according to Lin. “Every emergency department physician progress note is available to the patients on the portal. The only exception to this was the psychiatry notes. But, as of February 15, 2017, we will be turning on mental health notes for two [out of eight] psychiatry practices and see how that plays out for us—we will measure those outcomes.”
According to Lin, UCHealth’s Epic electronic health record system has more than 5 million medical records—of which 1.5 million are considered active—and more than 190,000 patients currently have opted to access OpenNotes through Epic’s My Health Connection patient portal. UCHealth adopted the Epic EHR in 2011.
About 10 percent of patients who’ve had a medical visit take a look at their notes, says Lin. However, he’s learned a valuable lesson: email reminders before and after a doctor visit can bolster patient engagement to view clinical notes.
“A best practice that we’re heading for is to remind the patient several days before their upcoming appointment, as well as reminding the patient after their recent visit, that their doctor’s note is available for them to view,” Lin observes.
Overall, Lin acknowledges that the road to implementing OpenNotes at UCHealth has been a bumpy one that initially included strong physician pushback. It’s a “sad story” about his socio-political naiveté as leader,” he adds, yet with a happy ending.
“We conducted some of the first research into OpenNotes back in 2001. Our project was called SPPARO—System Providing Access to Records Online,” says Lin, noting that the software consisted of a now-defunct, web-based EHR, an educational guide, and a messaging system enabling communication between the patient and staff.
A pilot study was conducted at a cardiology practice in which patients with congestive heart failure were provided with online access to their medical records, including all test results, progress notes, as well as doctor correspondences and letters. While the randomized controlled trial demonstrated that such a system was feasible and improved adherence, the clinical leadership at the university did not think a patient-accessible online medical record was a good idea for their healthcare organization.
Ultimately, Lin believes that physician acceptance of OpenNotes at UCHealth was significantly aided by a 2010 study that included more than 100 primary care doctors at three hospitals—Beth Israel Deaconess Medical Center in Boston, Geisinger Health System in Danville, Penn., and Harborview Medical Center in Seattle—in which 20,000 patients were invited to read their visit notes through a secure website. Since then, several studies have shown areas of patient safety and quality of care that benefit from this kind of open communication between physicians and patients.
“We were either bleeding or clotting edge back then—too far ahead of where the culture was,” comments Lin. “It took me 15 or 16 years to understand how to lead this kind of difficult cultural change at our institution and that long for the country as a whole.”
Currently, more than 10 million patients nationwide have access to their doctors’ notes online. To grow the number of OpenNotes participants to 50 million patients nationally, several foundations have committed $10 million to the effort to dramatically scale up the initiative on a national level.
Despite initial pushback from UCHealth’s physicians, Lin says he was able to better lead cultural change at the health system by convincing small groups of clinicians to adopt the OpenNotes concept in a phased approach.
“My favorite book now is Leading Change by John Kotter,” he comments. “Part of my work to try to socialize this through the culture was not to have large committee meetings, but one-on-one meetings with potential detractors in private where I could answer questions first without them being aired in a public forum.”
For those healthcare organizations looking to share clinical notes with their patients, Lin recommends against having OpenNotes be seen as an IT initiative—organizations must get buy-in from physicians by showing them the benefits to patients in terms of medication adherence, patient engagement and satisfaction, he adds.
“If it’s led by physicians and respected clinical leaders, you’re much more likely to be successful, rather than if it’s a mandate from administrative leadership or the IT department,” Lin concludes.
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