Author: CT Lin

CMIO, UCHealth (Colorado); Professor, University of Colorado School of Medicine

UCHealth launches OurNotes: how patients co-author clinic progress notes

As of November 2, 70 primary care practices went live with Our Notes. Read more about OurNotes here. Dr. Tom Delbanco and Jan Walker, researchers at Beth Israel Deaconess initiated and ran the study.

In brief, it is a way for patients, just ahead of an upcoming appointment to tell their provider what has happened to them since their last visit: changes in medication, new or changing symptoms, life changes. And then to ask up to 3 questions they’d like to discuss with their provider at the visit.

These notes were then automatically inserted into the providers’ progress notes. They could then be cited in their entirety, with no action needed by the provider while composing the rest of their progress note. Or, the provider could edit for clarity before signing the note. In this way, both patient and provider contribute the data from that visit, improving communication and collaboration.

We were so successful from our pilot test, conducted in coordination with Beth Israel Deaconess Medical Center (BIDMC), in our one primary care clinic, we have now launched it for ALL primary care clinics throughout UCHealth.

Our early findings showed that over 90% of providers (physicians and APP’s: advance practice providers) responding to surveys viewed OurNotes positively and wanted to continue, as did over 90% of patients who participated.

Not all patients who have a patient-portal account respond to the OurNotes questionnaire ahead of their visit. Those who do not, have a regular visit, just like before. About 15-20% of patients who have an appointment respond send an OurNote, and providers are using the notes regularly.

Others are catching the OurNotes trend as well, including Sanford health, UCLA, and the original OurNotes health system research partners: BIDMC, University of Washington and Dartmouth-Hitchock. Thank you to all the trailblazers out there for transforming patient-centered care.

CMIO’s take? More like this please! IT is a win-win-win: better engagement for patients, shared documentation for providers, more readable, narrative notes in our EHR’s.

EHR v Covid-19. Trends in testing, telehealth, hospitalizations

Welcome back to Where does the data lead?!

Here we are eight plus months into the pandemic and our testing volume and our positivity rates have been up and down. Testing volumes have varied because of limitations on receiving re-agents for our labs to process the specimens. It does appear that our test positivity rate, on the red line above, is increasing this month. This is also concordant with our Colorado state level data.

During this time, UCHealth has continued to grow as a system. We have opened a few new facilities in the past year, so the clinic volume, the patient population we serve, as well as the test volume has increased. So, lots going on here, and probably no one factor explains the pattern.

Visit Volumes at UCHealth

Our in-person visit volume for 2020 showed that precipitous drop in mid March (light red) and then nadir at mid April, with gradual recovery to 90% volume by July. At the same time (light green), our telehealth volume exploded at the same time, from a baseline of 20 visits a day, reaching a peak of about 4000 visits a day by mid April. As we figured out how to see patients safely in clinic, our in-person visits gradually returned and our telehealth volume declined, and we are now steady-state at about 1000 telehealth video-visits per day. Magenta is the scheduled telephone visits, a new visit type that Medicare began reimbursing. Blue is the regular telephone volume, essentially unchanged. The dark red is a gradual but consistent increase in patient portal messages, both gratifying that our patients have found a way to connect with their provider, and also worrisome in that this near-doubling of volume does impact the unreimbursed workload of providers in our system.

Cliffhanger

We are now back to our “cliffhanger” TV series. What will happen tomorrow? UCHealth has restarted our Incident Command Center given the increase in hospitalizations. Like many hospitals around the country, we are seeing a bump in inpatients with COVID-19. We had a peak of about 120 in April, then gradually fallen to a nadir of 17 inpatients in late summer, and are back up to mid 50’s this week, and rising.

CMIO’s take? Hang on to your hats.

My Interview on INFO BLOCKING With 33 Charts

https://touchpoint.health/podcast/vrx-how-virtual-therapeutics-will-revolutionize-medicine-a-conversation-with-dr-brennan-spiegel/

Thanks to Dr. Bryan Vartabedian for a fun wide-ranging conversation about INFO BLOCKING and our information transparency efforts at UCHealth over the past 2 decades. A trip down memory lane, and the potholes I’ve stepped in, and the battle scars from pushing the edge of what providers are ready for…

In case you are willing to come reminisce with me for 50 minutes…

https://touchpoint.health/podcast/vrx-how-virtual-therapeutics-will-revolutionize-medicine-a-conversation-with-dr-brennan-spiegel/

My Failure Resumé: A TALK

You know you’ve wanted to see it, hear it, and revel in the schadenfreude: CT Lin’s famous FAILURE RESUMÉ: a talk.

http://colorado.himsschapter.org/event/virtual-professional-development

CT has failed at so many things, it isn’t funny. Or maybe it is.

Date: Thursday, November 12, 2020. Noon, Mountain Time.

Thank you to the Colorado Chapter of HIMSS (Health Information Management Systems Society) for sponsoring and presenting My Failure Resume. Sign up (free) here.

Those of you who follow The Undiscovered Country know that this is by far my most popular blog post, in 3 years of weekly posts on health care, informatics, leadership, change management, and the general chaos of our lives.

I hope you can make it! Here are some random pictures to whet your appetite.

 

 

But what does it all mean? Come find out! Hope to see you there.

When Can I See Results in My Patient Portal?

We are all scrambling to put together simple documents to explain to patients and providers about INFO BLOCKING / SHARING coming in a week. Here’s our latest document. Link to full PDF here. Feel free to adapt this for your organization. We are also hoping our very smart Epic colleagues in Wisconsin can add a patient-preference setting into MyChart to accommodate the variety of patients out there, regarding seeing their own test results.

Remember, the rest of our INFO SHARING education documents are on my last blog post HERE.

CMIO’s take? Are you developing education tools that are simple 1-page explanations of complex topics? Let me know.

What is a MMOLC, and how is it solving Info Blocking?

The national discussion on Info Blocking / Sharing is resulting in rapid improvement. MMOLC helps a great deal!

What is a MMOLC? Read to the end.

Being part of the Epic userweb community of health systems and also the SmartServ list serve of Epic-using academic health systems is a privilege. There are lots of smart people doing and sharing important work regarding Information Blocking / Information Sharing. See previous blog posts.

Some things are becoming clearer: how to write brief, useful Executive Summaries on 1 page. How to improve the clarity of explanations. What positions to take regarding the INFO BLOCKING federal rule, given the lack of clear definitions in the 1200 page rule (!)

In our grid above, we have added a few new categories (Progress notes: Sensitive/Legal, and Progress notes: Behavioral Health).

I’m attaching the current versions of our working documents that we are broadcasting and discussing at our leadership meetings throughout UCHealth:

Updated INFO SHARING documents

  1. INFO BLOCKING executive summary with Release Grid
  2. How To Write an Open Note (with more and updated examples)
  3. This great editorial in the Annals of Int. Med by Dr. Heather Gantzer (thank you)
  4. This great online explanation by Dr. Brian Vartebedian
  5. An upcoming Office Hours with Steve O’Neill re: Open Notes in Mental Health

Feel free to use these documents to move the conversation at your organization forward. Although this is massive culture change for our providers and clinical staff, this is welcomed by our patients. And it is the right thing to do.

CMIO’s take?

I am grateful to all the brilliant colleagues in our online community. Hmm. Like an MMORPG (Massively Multiplayer Online Roleplaying Game) that my kids play (Minecraft, Rocket League), we have a MMOLC (Massively Multiclinician Online Learning Community). That is our superpower. Thank you.

UPDATED FOR INFO BLOCKING rule: UCHealth’s 16 year OpenNotes Journey (and a ukulele song)

Since the passage of the 21st Century Cures act and the INFORMATION BLOCKING rule, I’ve gotten a ton of questions about our experience with Open Notes and Open Results. AND A UKULELE SONG

patient20and20doc_2

Image courtesy of Healthcare Informatics

OCTOBER 2020 UPDATE. 

In this update:

  1. A ukulele song on Open Notes! What?! Read to the end…
  2. Our current interpretation of INFO BLOCKING rules and our current plans
  3. Links to important tip sheets that you can use/share

Since the passage of the 21st Century Cures act and the INFORMATION BLOCKING rule, I’ve gotten a ton of questions about our experience with Open Notes. Followers of this blog the Undiscovered Country will have heard this before. However, if you’re new here, welcome! I’m updating my original post from 2017. This now will include:

Important Links

  1. Link to my post on INFORMATION BLOCKING and the 1-page WHY plus 4-page HOW/WHAT that we are circulating at our Health System, affecting 6000 docs.
  2. Link to my post on HOW TO WRITE AN OPEN NOTE, with language suggestions.

UCHealth’s INFO BLOCKING settings

FYI, in regards to INFO BLOCKING, there are tons of nuanced decisions healthcare organizations are making, since the 1200 page rule still leaves some specifics quite vague, and the often-rumored FAQ that will clear up some of the vagueness is not here yet (less than 30 days until rule takes effect!). Here are our (interim) decisions at UCHealth:

  • All outpatient, emergency dept, urgent care provider progress notes will release immediately upon signature to the patient (already doing this)
  • All clinical notes associated with those visits (MA, RN, technologist) notes will also release immediately
  • All hospital progress notes will release to patients upon signature. This will include: H/P, daily progress notes, consult notes, operative reports, discharge summaries.
  • All medical student notes that are cosigned by physicians and used for billing will be immediately released. We are in discussions about the remainder of medical student notes that are NOT part of the legal medical record.
  • All resident and fellow notes will release immediate upon attending signature
  • All nursing and clinical notes that can be considered progress notes will release upon signature
  • NO psychotherapy notes will release to patient (they are not stored in our EHR)
  • NO notes that may be involved in legal, criminal or similar proceedings
  • NO notes that may ruin research randomization if revealed to patients
  • SOME of our psychiatry provider progress notes already release to our patients. Three of our 8 psychiatry clinics committed to Open Notes in 2017 and have had no issues. We are still working through this, in discussions to release more behavioral health progress notes (psychiatry, psychology, social work, case manager, others) to patients. There are some concerns about the possibility of risk to staff for patients reading some of these notes in real-time. Stay tuned!
  • All progress notes, inpatient and outpatient have a “DO NOT SHARE” button where providers can individually opt a note out of sharing with patient if it is deemed a risk. Our share rate is typically in the 90% range.
  • We already release all lab results immediately to patients, including sexually transmitted diseases, hepatitis B and C, etc.
  • HIV is on a 7 day delay and will move to immediate
  • We already release all plain film radiology and ultrasounds immediatelly.
  • Complex radiology: CT/MRI/PET are moving to immediate
  • Pathology, Cytology is moving to immediate.
  • We plan to manually release a handful of genetic tests, including Huntington’s disease only AFTER discussion with the patient. The remainder are moving to immediate release.
  • We have over 850,000 patients on our patient portal, so these settings will affect a great many patients.

Our 16 year journey to Open Notes

Thanks to @RajivLeventhal of Healthcare Informatics for a nice write up of our Open Notes work at UCHealth. The journey to “overnight success” can sometimes take a decade or so. To paraphrase Machiavelli: “Nothing is so difficult as Change in a large organization, as your proponents are, at best, lukewarm, and your detractors have ALL THE PASSION IN THE WORLD.” I discuss some of my hard-won lessons in Change Management on the journey to OpenNotes.

Link to story (March 16, 2017):
UCHealth’s OpenNotes Journey: From a Few Docs to Enterprise-Wide Acceptance

Original Research in 2001

The original research on SPPARO (System Providing Patients Access to Records Online, conducted in 2001, 10 years before the official, and better-named Open Notes initiative) is still available:

Ross, Lin, et al. Providing a Web-based Online Medical Record with Electronic Communication Capabilities to Patients With Congestive Heart Failure: Randomized Trial. J Med Internet Res. 2004 Apr-Jun; 6(2): e12.

Earnest, Lin, et al. Use of a patient-accessible electronic medical record in a practice for congestive heart failure: patient and physician experiences. J Am Med Inform Assoc. 2004 Sep-Oct;11(5):410-7. Epub 2004 Jun 7.

And … a song!

A ukulele song on Open Notes: Doc Prudence.

CMIO’s take? It has been a long time coming. Information Transparency for patients is the RIGHT THING to do. For myself, it was a 16 year journey from our first research studies, completed in 2001, until system-wide adoption of Open Notes for clinics, emergency depts and hospital discharge summaries in 2016. For others it is hitting them all at once here in 2020. It is a better place we are going to. In the meantime there is a lot of work and culture adjustment until we get there. Good luck to all of us.

You’re gonna release WHAT? WHEN? Info Blocking vs Info Sharing

Info Blocking means inpatient and outpatient progress notes released immediately to patients, along with lab results, CT/ MRI/ PET scan results, pathology results. Immediately. Ready?

My 1-page White Paper on WHY and 4 following pages on HOW/WHAT

LINK TO UCHealth’s INFO BLOCKING WHITE PAPER

What is Changing

The 21st Century Cures Act has an Information Blocking regulation that addresses the concern that some health systems or facilities delay or block patient information from other treating health systems, or from the patient. Of immediate concern to this CMIO is the impact this rule has on our health system, to wit:

We are already an Open Notes organization, since 2016, releasing outpatient provider progress notes to patients immediately upon signature. This applies to emergency department and urgent care notes, also to hospital discharge summaries. We’re happy with this, and proud to lead the charge in Colorado for information transparency. Same with immediate release of the vast majority of lab test results.

HOWEVER, we still delay some results 4 days, 7 days or 14 days depending on category (see above). The new INFO BLOCKING regulation stipulates that systematic delays like this will Violate the Info Blocking rule, and that the potential penalty for such delay is $1 million.

Wow.

This is great news for patients and patient advocates; they have long stated the maxim: “Nothing about me without me.” I love this idealism. Practically? We have struggled with how to make this happen. Now the feds have conveniently stepped in with a mandate. This makes the conversation easier.

Our big struggles ahead

  • Teach our inpatient providers to write notes that are ready for patients to read each day they’re in the hospital.
  • Teach ALL our providers how to anticipate patient concerns and the range of possible results coming from pathology (biopsies and PAP smears and other results that may show cancer or severe disease). Same with complex imaging like CT scans, MRI’s, PET scans, mammograms. Same with lab results that may show genetic variants, like Down’s syndrome.

How I made this

Beyond the specifics of the INFO BLOCKING rule, this also illustrates the value of Form Factor and Communication Strategy. My mentor always taught me: if you write a white paper executive summary, every additional page beyond one side of one page cuts your readership in half.

So, for my white paper, I have written a ONE PAGE summary of WHY this is important and what action is needed. For those who just need “at a glance” the color grid in the center tells the story of exactly what is changing. And because data alone does not change minds, the call-out box at the bottom includes a few quotes from selected leaders, telling a brief story.

Finally, if you get to the end of the page and are interested in doing something, I have 4 more pages of HOW and WHAT to take you to the next level.

This, COMBINED WITH a road show, where I am going to every major physician leadership meeting, is how I’m getting the word out. There is, of course, much more work to do at the individual provider and manager and service and clinic level, but I’m trying to give everyone a running start. There’s not much time left.

CMIO’s take? We all have hard work ahead. This is a federal mandate, so 4000 hospitals, countless health systems and clinics will be facing this as well. The link to my white paper here (and above) is my contribution. I hope this helps you get to the right place with this regulation AND with doing the right thing for our patients.