By Thomas H. Payne, MD; Sally Beahan, MHA, RHIA; Jane Fellner, MD; Dan Martin, MD; and Joann G. Elmore, MD
Patient Portals that allow viewing of clinical notes and hospital discharge summaries: the University of Washington OpenNotes implementation experience
Many healthcare organizations are striving to improve patient engagement by facilitating patient access to clinical notes in the electronic health record (EHR) via patient portals. The University of Washington Health System (UW Medicine) in Seattle, WA, was an early participant in research on patient portals as one of the three OpenNotes study sites.
Since the time of this study, the OpenNotes initiative has now grown into a national movement to improve patient engagement by granting patients the ability to view clinical notes in the EHR. Based on UW Medicine’s positive experience during the pilot study, the organization opened patient access to all clinical notes via an electronic portal throughout its entire health system.
Because UW Medicine has recently transitioned to facilitate patient viewing of all clinical notes and discharge summaries via an electronic portal, this article describes the steps taken at UW Medicine to assist health information management (HIM) professionals in understanding the issues involved in such a transition.
The transition was accomplished after careful consideration by many individuals and groups, and the move to patient viewing of clinical notes and discharge summaries at UW Medicine has involved a large number of patients and notes with few reported problems. This article was prepared by representatives at UW Medicine to provide a description of the main discussion topics, policies developed, and problems addressed with the OpenNotes portal implementation to assist other organizations in understanding the issues involved and help them manage their own transition.
Reconciling Competing IT Demands
UW Medicine is the patient care delivery system of the University of Washington. There are four UW Medicine hospitals with 64,000 hospital discharges and 1.6 million outpatient visits each year. The clinics associated with the four hospitals, as well as the 12 neighborhood clinics, primarily use different EHRs and web portals than those used by the emergency department and inpatient services.
Six years before granting access to patients on a system-wide basis, UW Medicine granted clinical note access to 2,000 patients in one of UW Medicine’s largest primary care clinics using a locally developed web portal. Reception by both patients and physicians was generally positive and spurred interest in expansion to more patients and providers.
The OpenNotes initiative has gained attention during a time when most healthcare organizations, including UW Medicine, have been involved with many other health information technology initiatives. These include adoption of processes and reports to qualify for incentives from the “meaningful use” EHR Incentive Program, EHR adoption with variable acceptance by physicians and the consequent pressure to address their concerns, the national transition from ICD-9 to ICD-10-CM/PCS to support billing, development of accountable care organizations (ACOs) as a new mechanism to manage and finance care, shifting payment away from fee-for-service and the growth of pay-for-performance programs, and new security threats to information systems. These and other initiatives have led to unprecedented demand for IT projects and support. In this context, proposals to adopt OpenNotes at UW Medicine and elsewhere competed for organizational priority and the IT resources required for the transition.
Making a Joint Decision to Implement OpenNotes
The OpenNotes idea was first discussed with clinical and administrative leaders at committee meetings, including the faculty practice plan (UW Physicians) Clinical Practice Committee, the Health Information Management Committee, EHR oversight committees, and Ambulatory Care Committees at each UW Medicine entity. In these meetings, OpenNotes was described, the organization’s institutional experience with patient portals and published literature on patient note viewing was reviewed, and committee members’ opinions were solicited on adopting the OpenNotes approach in a limited or system-wide fashion as well as any anticipated issues.
In these discussions, the main arguments favoring the introduction of OpenNotes throughout the healthcare system were that OpenNotes is consistent with UW Medicine’s ‘Patients Are First’ campaign, and the OpenNotes pilot study was popular with both patients and providers, causing much less additional work and disruption than feared. After months of informal discussion, several key leaders proposed adopting OpenNotes throughout the health system, and staff tentatively decided to do so.
Concerns led to an agreement to make new policy decisions in preparation for this transition, such as those listed in Table 1 below. UW Medicine’s Patient Portal Oversight Committee and Health Information Management Committee were the most involved governing bodies in identifying needed policy decisions and developing these policies or referring them for decision. UW Medicine’s senior organizational leadership felt that developing a broad communication plan was the best way to identify concerns in advance of the transition and to build consensus affirming this direction.
|Table 1: Questions from OpenNotes Planning Discussion and UW Medicine Decisions
||UW Medicine Decision
|Should access be granted gradually, and if so, which clinical settings should be the first and at what pace should we extend access to other settings?
||Implementation to occur simultaneously at all clinical sites with a broad communication plan to all providers and patients.
|Should this apply to inpatient, emergency department, or outpatient notes?
||Outpatient, excluding emergency room. Only discharge summaries viewable for hospitalized patients through separate portals.
|Should this apply to all UW Medicine entities, if so, simultaneously or in a staged fashion?
||UW Medicine entities sharing the same EHR database would go live at once.
|If access to viewing were granted, should only notes written after this decision be viewable by patients, or should notes written before the decision also be viewable?
||Only notes signed after the implementation date are viewable, not notes written before the implementation date.
|Should it be possible for a clinician to choose not to participate?
||No. All UW Medicine physicians, physician assistants, nurse practitioners, and nurses must participate.
|Should it be possible to exclude all notes for some patients?
||No. However, there is policy in place to block access to the portal.
|Should all notes be viewable or only those pertaining to face-to-face visits?
||Only notes from face-to-face visits. This excludes telephone notes, abstracts, and internal communications from patient viewing.
|Should all notes of certain types be excluded from view by any patient?
||No. Individual notes can be blocked, but no note types (i.e., social work notes) are excluded.
|Should it be possible to block viewing of some notes, and should this be left to the note author alone to decide?
||Yes. Policy describes how clinicians can block individual notes.
|Should notes in draft be viewable or only completed signed notes?
||Only completed signed notes are viewable on the patient portal.
|Should there be a delay between the time the note is completed and the time it is viewable on the portal?
||Notes are viewable immediately after the encounter is closed by the author, except if written by a trainee (student resident or fellow) as below.
|Should notes by residents, students, fellows, and other trainees be viewable by patients, and if so, should review and signature by the attending physician or supervising clinician be required first?
||Notes by trainees are viewable by patients after they have been signed by the attending physician or supervising clinician.
|Should we notify patients that a new note is now available for viewing? Should this be via e-mail or only when the patient has logged in to the patient portal?
||For the first 10 months no e-mail was sent to notify patients that a new note was available; currently they are sent. E-mails are also sent when new laboratory, imaging, and pathology results or messages from the clinic are available.
|If a patient disagrees with what is said in the note, what should happen?
||Patients are encouraged to report errors they find in notes to their provider for correction. If there is disagreement between the patient and provider on note content, policies for amendment of the record are followed. (See policy in Table 2.)
Developing a Communication, Public Engagement Plan
UW Medicine’s communication plan included numerous presentations to over a dozen committees, e-mails to providers, an article on a public-facing website, documents for staff, trainees, and faculty on internal websites, weekly medical staff and leadership e-mail newsletters, and a detailed description of OpenNotes and the rationale for its adoption in e-mails from the practice plan president to all medical staff (readers interested in seeing this e-mail can contact Thomas H. Payne at email@example.com). Practicing physicians known in UW Medicine’s community as IT clinician-leaders included their personal e-mails in these communications to solicit feedback and address concerns.
With the help of the public information officer, an article was drafted for UW Medicine’s health sciences public electronic newsletter describing OpenNotes and soliciting comments or concerns. That article had 1,113 unique page views and included a four-minute video of some UW Medicine doctors and patients discussing their OpenNotes experience, along with the e-mail address of one of the authors of this article to answer further questions from viewers. Immediately before implementation, exam room and clinic waiting area posters were created and distributed to clinics for posting at their discretion. Provider- and patient-focused frequently asked questions (FAQ) documents were prepared and circulated.
Getting the Logistics in Place
To get things ready, UW Medicine configured its EHR patient web portal to add clinical notes to the personal health data viewable on the portal. Compared to other technical tasks the EHR team has undertaken, configuring the portal for note viewing was substantially less challenging. Much of the challenge was adjusting the configuration according to organization policies, which are described in Table 2 below. Providers or staff had the option of selecting “Confidential Note” under “Reason for Visit” to block individual notes from patient viewing when needed.
|Table 2: Policies Created or Updated During Preparation for OpenNotes
|Guidelines for Restricting Notes in eCare (UW Medicine patient portal)
|Adult Proxy eCare Access
|EHR Documentation Principles
|Amendment of Protected Health Information/Designated Record Set
Note: Readers interested in seeing examples of the above policies can contact Thomas H. Payne at firstname.lastname@example.org.
The OpenNotes implementation team needed to answer the many questions listed in Table 1, either by consensus or delegation to decision-making bodies, and to pick a start date. Opinions ranged from delaying the decision for six to 12 months to proceeding as soon as possible when preparation was complete.
It was anticipated that existing health information management policies based on older paper-based health records would need review and updates, and that new policies might be required for patient portals. Among these were the medical record amendment policy describing steps for patients to amend their medical record; changes to the proxy access policy (permitting a designee to view the record) because access granted to a proxy now included viewing notes and some patients might wish to rescind proxy access to prevent note access; and policies regarding portal access by adolescents and others. Finally, UW Medicine reviewed and edited institutional guidelines for professionalism in documentation and principles that should be followed.
Contention Between Patients, Providers a Concern
The communication plan and committee presentations resulted in many discussion topics. Some providers expressed concern that contention between patients and providers over note content would be more common when patients could easily view their notes. Examples included notes concerning disability evaluations. As a result, UW Medicine updated its note amendment policy and reviewed state and federal laws governing note amendments. The organization also publicized the amendment procedures so that patient requests for correction or amendment could be efficiently handled.
There was interest in how providers could exclude patients with known severe behavioral, psychiatric, or medical illness from the ability to view notes. These were patients who providers felt risked more harm than benefit by viewing notes. UW Medicine established a policy for providers to propose individuals for exclusion and for the Health Information Management Committee to decide if this should be done.
Another issue that generated discussion was use of respectful language in notes, leading to guidance/training for all physicians, staff, and trainees on better language use. There was extensive discussion about whether to exclude all Sexual Assault Center and social work notes, but the decision was made to only exclude individual notes designated by staff as “Confidential Notes.”
Patient Access Begins
Initial discussion regarding full implementation of OpenNotes at UW Medicine began in November 2013. In May 2014, the implementation team decided to grant access to inpatient discharge summaries beginning June 10, 2014. After discussion by clinical oversight committees, some clinical leaders felt insufficient publicity had occurred and some physicians and residents were unaware of this change. For this reason, the inpatient discharge summary transition was postponed for three weeks.
While there were widely diverse opinions regarding timing, ranging from immediate implementation to extended delay, in February 2014 the oversight committees decided to allow patient access to all outpatient notes except the sensitive note types discussed above. After substantial discussion, the Patient Portal Oversight Committee agreed to recommend the transition in September 2014 and subsequently modified this to October 2014. This recommendation was endorsed by the UW Medicine Health Information Management Committee and active planning for the transition began.
On October 21, 2014 clinical note viewing was added to the UW Medicine patient portal that already included access to laboratory results, radiology and pathology results, after-visit summaries, and patient medical history.
There was a six-year lag time between the research trial period for patient access to clinical notes and the system-wide adoption. This time lapse did not occur because of adverse experiences of patients or providers during the research activities or during the planning phase. The time lapse was a result of the effort required to present, discuss, and prepare large numbers of diverse providers, consider and develop new policies, and address concerns about potential adverse effects and additional provider time requirements. The pressure of delivering on many other mandated EHR and IT projects contributed to the time lapse. OpenNotes was one of many initiatives competing for the attention of UW Medicine’s committees and leadership, and was generally considered less urgent than many other contemporaneous transitions including adoption of an outpatient EHR and computerized practitioner order entry.
During the month of October 2015, one year after opening notes to patients, 537,717 clinical notes were created at UW Medical Center, Harborview Medical Center, UW Neighborhood Clinics, and Northwest Hospital and Medical Center. Of those, 239,644 (45 percent) notes were created on patients with access to the system’s patient portals. Those patients viewed 15,932 notes, or roughly seven percent. During the first year, providers blocked fewer than 10 notes per month from the patient portal by specifying the visit type as a “Confidential Note.”
Staff only recently implemented reports allowing the ability to count the number of patients viewing notes. Before this functionality, staff were unable to measure patient access frequency and therefore do not know the rate of viewing from the beginning of OpenNotes access. UW Medicine staff initially decided against sending e-mails to patients upon note completion, but began sending e-mails 10 months after full implementation of OpenNotes, based on the oversight committee’s judgment that it was important to encourage participation.
Feedback on the Transition has been Uneventful
There was very little feedback, either positive or negative, from patients in the first year OpenNotes was fully implemented. It is not known if this is because few patients were aware of their ability to view notes, because few chose to view notes, or because note viewing generated little concern or desire to contact the patient’s care team. Similarly, there was very little feedback regarding availability of inpatient discharge summary viewing, and staff does not yet know how many discharge summaries were viewed through the inpatient portal.
The transition, in summary, has involved a large number of patients and notes with few reported problems. This may be because of UW Medicine’s pioneering involvement in early OpenNotes research, the cautious and detailed preparatory steps taken, as described above, because OpenNotes is regarded to be a natural next step in use of EHRs, or a combination of these reasons and others. It is not yet known in what detail UW Medicine’s patients view their notes. The organization’s plans are to increase patient viewing, to monitor usage, and to conduct more formal evaluation of positive and negative effects on providers and patients.
The authors gratefully acknowledge the Robert Wood Johnson Foundation, Cambia Health Foundation, Peterson Center on Healthcare, and Gordon and Betty Moore Foundation for their support of this initiative of which UW Medicine was only one part, and the OpenNotes team at Boston Beth Israel Deaconess Medical Center for their support at every step.
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Dr. Thomas H. Payne (email@example.com) is professor of medicine, University of Washington, and medical director, information technology services, Sally Beahan (firstname.lastname@example.org) is director, health information management, Dr. Jane Fellner (email@example.com) is clinical associate professor, department of family medicine, University of Washington, and associate medical director for ambulatory EHR, information technology services, at UW Medicine. Dr. Dan Martin (firstname.lastname@example.org) is associate professor, department of medicine, University of Washington, and chief medical information officer at Seattle Cancer Care Alliance. Dr. Joann G. Elmore (email@example.com) is professor of medicine at the University of Washington.
Payne, Thomas H.; Beahan, Sally; Fellner, Jane; Martin, Dan; Elmore, Joann G.
"Health Records All Access Pass"
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