June 2016

OpenNotes Takes Hold in the Northwest
By John Santa, MD, MPH
For The Record
Vol. 28 No. 6 P. 28

There's no place quite like Portland, Oregon. It's creative, hip, progressive, and a foodie's paradise. It needs to be all those things because it rains approximately 160 days each year. Portland's uniqueness makes it an ideal spot to try out new ideas—even when it comes to medical records, which typically aren't associated with terms such as "exciting" and "groundbreaking." But 30 years ago, a lot of folks felt the same about coffee, and the Northwest proved them wrong.

In the past few years, more medical communities have become familiar with OpenNotes, a national movement to make sharing clinician notes and fully transparent medical records the standard of care. Research led by Tom Delbanco, MD, and Jan Walker, RN, MBA, at Beth Israel Deaconess Medical Center in Boston, Geisinger Health System in rural Pennsylvania, and Harborview Medical Center in Seattle, has brought to life what secure, easy access to medical records could do for consumers.

What a concept: Clinicians making their notes readily available, which is something that, according to Delbanco and Walker's 2010 study, 99% of patients said they wanted.

A Better Future
In Portland and southwest Washington state, We Can Do Better, a small consumer organization, agreed to host a community meeting in June 2013 to discuss OpenNotes. A nonprofit dedicated to bringing together people who share the values of better health care for all, We Can Do Better was interested in exploring how health systems and large medical groups can start sharing notes with patients.

In the spring of 2013, I joined the discussion at a community center in Portland's Hoyt Arboretum. Phone calls were made to contacts in each system or medical group we thought may be able to influence a decision to implement OpenNotes. We also reached out to representatives from consumer and professional organizations, government, and local employers.

Because all of the invited health systems and medical groups used an Epic EMR, our group asked Epic if their system would be able to support OpenNotes functionality. The vendor was quick to confirm that the technology was not an obstacle. No doubt, the collective power of clients coming together had a strong impact on Epic's quick response.

Initial Response
As was suspected, the biggest challenge for organizations adopting OpenNotes was cultural; would clinicians embrace or oppose openness? Organizations also expressed concern about how long it would take to implement the initiative.

Fortunately, leaders from the VA, who had spearheaded their organization's OpenNotes efforts earlier in the year, were present at the meeting. Their experience and encouragement made a huge impact on attendees.

By the end of the morning, all of the organizations agreed OpenNotes was the "right thing to do" and were willing to pursue internal discussions. Despite skeptics among us who wondered how an initiative that did not carry financial rewards, could potentially irk some physicians, and would likely compete with other IT priorities would ever meet its goals, the first OpenNotes consortium was launched.

It was assumed there would be months, if not years, of discussions; however, a breakthrough occurred when Homer Chin, MD, the first chief medical information officer (CMIO) in Oregon, who recently retired from Kaiser Permanente Northwest, agreed to lend his IT expertise to the OpenNotes movement. Chin helped participants understand the various versions of Epic in play, the capabilities of portals, and the intricacies of patient privacy. Inevitably, he wrapped up each explanation with "So, when can we count on you implementing OpenNotes?"

Full Steam Ahead
In the fall of 2013, Kaiser Permanente Northwest invited several consortium organizers to attend a meeting about OpenNotes. Patients were also invited, and they were unwavering in their desire to see OpenNotes implemented.

Seven months later, the consortium gathered for its third quarterly discussion. As usual, Chin asked those in attendance to update their progress. Kaiser Permanente Northwest CMIO Mike McNamara, MD, and Director of Optimization and Innovation Rob Unitan, MD, had great news. "Kaiser will make clinician notes available to all 550,000 of our patients in April of 2014, four months from now," McNamara said.

Every CMIO in the room knew this development was a game-changer. As a result, the consortium shifted its focus from discussing OpenNotes to implementing OpenNotes. Over the next four months, Frequently Asked Questions were developed for patients, clinicians, and the community in general. Communication staff from several of the systems moved through multiple drafts of a joint press release.

All agreed a one-size-fits-all approach to OpenNotes would not be in the health care community's best interests. Kaiser Northwest, The Vancouver Clinic, The Portland Clinic, and PeaceHealth pursued "big bang" (a systemwide outpatient rollout) implementations over the next year. Meanwhile, Legacy, Providence, Oregon Health & Science University (OHSU), and Salem Health launched pilots of varying sizes that expanded over the next year. Two years later, Legacy and OHSU opted for organizationwide implementations.

OCHIN Inc, a unique organization that provides an ambulatory version of Epic to more than 90 community clinics in multiple states, made it possible for each of these operations to "flip the switch" and turn on OpenNotes whenever they were ready.

Colleagues at OpenNotes in Boston assisted at every step, including helping to spread the word in the community about the initiative's nuances. The consortium identified similarities and differences among participants. For example, some sites included mental health notes, while others did not. Other variances included whether notes were made available to adolescents. Some organizations promoted the availability of OpenNotes to clinicans and patients, and some implemented strategies to remind patients that clinician notes were available to be read.

No matter the approach, most CMIOs described the implementations as being a "nonevent." Traffic to portals increased, sometimes doubling or tripling depending on how OpenNotes was promoted, but physician e-mail traffic remained flat. Many clinicians actually wondered whether their notes were being read. Patient feedback was sporadic, but what was received was measured and carefully thought out.

Today, two years after community implementation, approximately one-half of patients in Portland have electronic access to clinician notes, the largest percentage of any US metropolitan area. All Northwest implementations were self-funded, and no significant technical obstacles have occurred. Survey results continue to be consistent with Delbanco and Walker's original findings: OpenNotes greatly benefits patients, with little additional work for clinicians.

I am thrilled to be part of the national OpenNotes dissemination effort. In April, I presented the concept to health care organizations in Minnesota, Wisconsin, and Idaho, and look forward to moving ahead in those states. The "water" is not different in the Northwest. We suspect there are more influential organizations that will catalyze both competition and collaboration in their region to bring OpenNotes to the consumer community. And in many cases there also will be clinicians who will anticipate that demand and respond accordingly.

In the case of OpenNotes, the right thing to do may be inexpensive, but it is no less transformative.

— As director of dissemination for OpenNotes, John Santa, MD, MPH, is responsible for bringing the OpenNotes movement to clinical sites throughout the country.

Based at Beth Israel Deaconess Medical Center in Boston, OpenNotes is supported by the Robert Wood Johnson Foundation, the Gordon and Betty Moore Foundation, the Peterson Center on Healthcare, and Cambia Health Foundation. To learn more, visit www.opennotes.org.