Open notes in a Resident clinic: research study results

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Research study paper is here:    http://ow.ly/6eY530jYZJy

We’re published! Thanks to co-authors Bradley Crotty MD, Corey Lyons MD, and Matthew Moles MD, we helped a multi-health system collaborative to study the idea of Open Notes in primary care residencies (family medicine and internal medicine at University of Colorado Health system), with research findings above.

Ultimately there is some anxiety from both faculty and residents about patients reading their written progress notes online, after the physicians have signed off on those visit notes. We are happy to claim that our program, of all the training programs was least optimistic that this would turn out well for our physicians and patients.

Overall, though, since we gathered this survey data, we have gone on to turn on Open Notes throughout our health system (UCHealth) and now uniformly offer Open Notes to all patients in our 700 clinics, 11 hospitals, and 21 emergency departments. The fear that the “world would come to an end” has not yet come to pass, and we are hearing positive things from our patients about their ability to read notes and benefit from them, including:

  • I often forget much of what we discussed in the visit, now I can go back and refresh my memory
  • Sometimes my wife asks me “what did the doctor say?” and now we can go review it together
  • Sometimes my other doctors don’t receive the consultation letter from my specialist, and now I can show him/her that letter/note from my patient portal. I can be in charge of my own information
  • I can use my doctors note to look up words I don’t understand and get more background information so that I can ask more intelligent questions at my next visit; I feel like a part of my own healthcare team

CMIO’s take: it is good to study what we do. As Robert Anderson MD, one of my mentors told me: “We should use the laboratory of our direct patient care to study and learn. Everything we do with patients should be evaluated and can be improved.” Thanks, Bob!

I wanted Vicodin, not Herbal Tea (nytimes)

We are in the midst of a national opioid crisis. It is a crisis, partially, of our own making. In the past decade we physicians were criticized for not adequately addressing the pain of our patients, to the point of creating another vital sign: “pain score.” And then dutifully tracking this score and catering to it, and addressing pain, often with rehab therapy, with more aggressive interventions, injections, surgeries, and, yes, sometimes with pain meds, including narcotics and anxiolytics.

And on top of this, we layered “patient satisfaction” as a rubric, and now a method of affecting physician reimbursement. What could go wrong? Isn’t satisfying our patients a core precept of our identity as physicians?

Actually, come to think of it… no.

We are here to help our patients get better.

To cure sometimes, to relieve often, and to comfort always.
–15th century folk saying

But there’s nothing in that saying that says “and always write for a narcotic script if you’re in danger of getting a low satisfaction score.

So, here we are, with an opiate crisis, and faced with the very difficult task of reducing or eliminating opiate use in patients whom we have PUT on chronic opiates. So, this NYtimes article is timely and fascinating.

In fact, we are in the midst of designing and implementing an ERAS program (Enhanced Recovery After Surgery) in our health system, to entirely eliminate the use of opiates before, during and after surgery. Apparently pioneered by surgeons at Duke University, we are well on the way to experiencing similar benefits for our patients, faster recovery, reduce hospital stays, higher patient satisfaction.

This is reminiscent of Atul Gawande’s book “Better” where he describes the idea that “If even elite athletes have coaches to improve their game, maybe surgeons should have coaches.” And then finding that having a former mentor observe him during surgery, he received pages of notes on how to improve his operating technique and outcomes. Hmm. We should do more of this, inspecting our usual practices, and working out how to continuously improve.

CMIO’s take? There is always something new to learn.

Happy holidays from the Large PIGs, JIG, and CMIO

Dave Corry arriving late to our group photo, to the CMIO’s amusement and dismay

I hope that you are making plans to celebrate the season, to connect with friends, colleagues, family, and take time for yourself.

I consider myself so fortunate to work with such a great group of informaticists or informaticians (inforMAGICIANs?!), or informatics people, whatever we call ourselves. The work we do, sometimes seems like a grind, but keep in mind, fellow informagicians, that we strive to improve the lives of patients, colleagues and staff by improving the information systems we use for the greater good. 

We try to keep it light in our naming of projects and committees. For example, our Joint Informatics Group (including clinical informatics nurses as well as physician informatics) is JIG. Our physician informatics group are the PIGs. This leads to the New PIG book club, the Small PIG leadership group, and the meeting, which encompasses all physician informaticists: Large PIG. 

And, be sure to throw up your hands and have a good laugh once in awhile. By the way, here’s an updated picture with Dave raising a glass. 

CMIO’s take? Here’s to you and the good work we all do. Cheers!

Where does creativity come from?*

“Where does creativity come from? We don’t know but we are certain that it doesn’t come from our laptops” –John Cleese

Thank you, Sir Cleese. I have enjoyed your movies, your quips, your oeuvre, and even the way you say “oeuvre.” And now, you give talks on creativity.

In my readings, I must agree, working on computers, on laptops is simple, is portable, allows us to store our thoughts in the CLOUD to avoid getting our papers lost in some stack. And yet, the non-verbal result of our tapping away at our computers, our laptops, our tablets, our phones, is an implied communication that we are in our own bubble.

Furthermore, using keyboards seems to reduce the ability for our brains to engage in encoding incoming information, with research showing that students learn better when they take notes ON PAPER as opposed to using an electronic device, maybe because SLOW handwriting forces a brain to choose the important words rather than take down words verbatim, and maybe because having an open laptop (often open to SOME other interesting website) distracts us AND OTHERS SITTING BEHIND US to losing focus and not really listening.

Finally, numerous books on creativity talk about how computers may be terrific at creating beautiful documents and flyers, but are generally terrible at restricting the free flow of ideas that is only possible with pencil, colored markers, sticky notes, lots of paper and scissors. Some advocate for having TWO desks in your office: one for creative work that has NO electronics, only paper manipulatives, and one for the computer, when the creative work is done, to put the completed work into a pretty format for printing or electronic storage and transmission.

I’ve taken to this model and try to do creative work away from my computer now. I also take notes in a small black book, not on my phone, and I’ve found this (although not searchable) a great way to better encode and remember discussions.

CMIO’s take? Keep in mind where creativity comes from
and where it doesn’t come from.