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:
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.
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.
And now, CMS’s latest regulation on Information Blocking, part of the 21st Century CURES act, has detailed stipulations on what must be released to patients, including Open Notes in clinic, in the emergency department, and for inpatient notes. It turns physician paternalism on its head: we should RELEASE all information to patients UNLESS there is a compelling reason not to.
If your organization is NOT scrambling to get this in front of your providers to discuss: immediate release of progress notes, consult notes, history/physicals, operative reports, discharge summaries, laboratory report narratives, radiology report narratives, pathology report narratives, THEN YOU ARE BEHIND THE EIGHT BALL.
Full disclosure, I was part of a Robert Wood Johnson sponsored event to explain Open Notes to congressional leaders in Washington DC 2 years ago. Little did I know we’d end up here, with the regulations not only catching up to the literature (benefits of Open Notes in ambulatory settings), but surpassing it and requiring Open Notes (patients ability to access their providers notes written about them and their are) for Inpatient Settings. We published our experience with Inpatient Open Notes in 2013. The results: lukewarm. Our providers and nurses were very concerned before the project, somewhat less concerned after. Our patients were underwhelmed with the offer of viewing their notes. Others have written about inpatient Open Notes, that potential challenges with communication, anxiety and increased workload may negate the benefits. Specifically patients and providers were concerned: will providers STOP writing important discussions and debates in progress notes because of fear that the patient or their family will immediately see them (eg: “there are several possible cancer diagnoses we are considering that might cause this”, OR, “be careful when you go in that room, the father can be very aggressive”). Certainly, with more care and thoughtfulness, we can write better notes, but should we require that? Are hospital providers not already working too-long shifts and already burned out from excessive administrative work? I’m uncertain.
I am concerned that MANDATING release of inpatient daily progress notes immediately to the patient may result in significant unintended consequences, with benefits that may not overcome the risks.
But, here we are. The full details and FAQ of Information Blocking (how soon must notes/results be released? how extensively? Retroactive to ALL notes written electronically (for us, back to 2003)? are still pending, and yet the regulation goes into effect in November. 2020. Soon.
We have had rules for built-in time delays to the release of test results to patients that have been in place since 2003. These applied to both outpatients and inpatients. We have been pleased that our release of blood tests to patients has been “immediately” since 2003. However, we do delay complex radiology imaging (CT, MRI, PET) for 7 days and pathology results for 14 days so that potential cancer diagnoses are communicated from the provider rather than “discovered” online.
This will now have to change, and urgently. I am convinced we can get to IMMEDIATE release of all results and notes, but it will take some hard thinking, some hard cultural conversations, some letting-go of old traditions, some problem-solving of potential new problems, lots of anticipatory planning (how to educate patients on what they might be the first to see online), and also (as per the Leading Change principles) to grieve the loss of the “old ways.”
IS THIS THE END OF SECRECY IN HEALTHCARE?
So, this is the slide deck content for the talk I gave at CHIME (College of Healthcare Information Management Executives) last fall, and at a couple of other national venues, detailing the information transparency efforts we are undertaking at UCHealth:
This is the curve of percent of patient appointments each month for the past 3 years, with patient portal accounts. I blogged a version of this back in March. Back then, if you drew a straight line from 2017 through FEB 2020, it looks pretty linear. Then, BOOM, a sharp uptick in March and April. The percentage increases from 71% to 77% in 2 months. Then it has stabilized and flattened in the 76-77% range since then.
So, in 2017 we were around 56%, right in the ballpark.
I think we understand the bump in portal usage in March and April: our dramatic upscaling of telehealth by 200x from 20 per day to 4000. In order to schedule patients for a telehealth visit, we required the patient to register for and log in to our My Health Connection (Epic’s MyChart) patient portal at UCHealth. Nothing like a pandemic and an available well-oiled telehealth service to bump patient portal stats.
Now, more of our patients can take advantage of: messaging their provider, refilling their prescriptions online, accessing price transparency estimates of anticipated procedures or services, viewing and requesting changes of the: medication list, diagnosis list, view their provider’s progress notes (Open Notes), view their radiology reports AND actual images (UCHealth is one of the first patient portals in the country to offer this).
However, what explains the flattening since then?
Theory #1: It’s those surgeons!
The theory: well, all surgery clinics completely shut down during most of March, April. And, WE ALL KNOW that surgeons are terrible with patient portals (rampant overgeneralization). The answer: Actually, NO. Once we select ONLY primary care practices and exclude surgeons and medical specialists, the same curve occurs. It is not the opening and closing of surgery clinics.
Theory #2: its those Seniors!
The theory: well, since most older patients have been staying home, and a good number of them don’t have access to smartphones or laptops or PC’s to do telehealth visits, it must be ONLY younger patients coming in, who of course have excellent rates of signing up for the patient portal for telehealth, right?
The answer: Again, NO. Turns out, if you filter out all patients over age 65, the same curve occurs.
So, what is happening here? Are we bumping up against the natural limit of Coloradoans who own smartphones and/or computers? Have we indeed registered ALL patients who will ever agree to signing up for a patient portal for any reason?
Or, have we gotten lazy and gone back to “hey lets encourage patients to come back to clinic!” and thus relaxed our vigilance at setting up patients for a free portal account?
Or is there another theory, another slice of the data I haven’t thought of?
CMIO’s take? I’m asking for YOUR help! Send me an idea, a theory I can slice on this data and see if it explains the plateau!