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In Search of Technology that Improves Geriatric Care

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Don’t Dump: Helping the ED with SNF transfers

[Woo-hoo! GeriTech is pleased to welcome its very first clinician guest post, by Graham Walker, MD]

To dump: the act of defection; to put down or abandon (something) hurriedly in order to make an escape; to abandon or desert (someone).
To dump on: to treat badly.
If you understand these definitions, you understand why we call them “nursing home dumps” in the emergency department. The dementia patient transferred for confusion. The comfort-care-only patient transferred for cough. Now please don’t misconstrue my cynicism; many nursing homes do a great job, and have an incredibly difficult set of patients to care for; I’m frequently amazed at how many days and how many interventions they’ve tried before the patients are transferred. I’m not suggesting that all nursing home transfers are “dumps,” but certainly a number of them are.
The vast majority of the time, the staff member at the nursing home who felt the patient needed to come to the ER is gone, having “just left shift,” with a transfer sheet only stating “confused,” with a pleasantly demented patient wide-eyed, staring at you in the face without any particular complaint. At my hospital, we’re frequently much luckier, with pretty good communication and notes to know how the patient ended up in the ER.
So what is an ER doctor to do? It’s 2am, you’ve called all the family members, and no one’s answered. No one that knows the patient is at the skilled nursing facility. The paperwork gives you nothing about how the patient is “confused,” or “altered.” Your exam is normal. Here’s how it usually goes:
1) Order a CT head, cath UA, basic labs, EKG.
2) Give some IV fluids.
3) Wait until morning until you can get some more information, possibly having to sedate the agitated, demented patient and complicate their mental status even more.
Could there possibly, possibly be a better way? I think so. Enter SNFTube.

SNFTube: An idea to help the ED understand a SNF resident’s baseline

What if we had a way to know a demented patient’s–or any patient’s–baseline mental status and function? What if the doctor at the bedside could see a video of the patient’s baseline, best-case-scenario mental status and cognitive function, complete with some data on their most recent MOCA, along with some video of their baseline function? Do they move all 4 of their extremities? (Frequently when someone’s problem list already includes 3 prior strokes, it’s hard to know if their left-sided weakness is new or old.) Are they bed bound? Do they typically feed themselves? Can they get themselves dressed? Are they typically this agitated and angry at night? 
This information would be incredibly helpful to any physician trying to make critical decisions about someone’s mother, father, sister, or brother, especially when no one is there to be able to provide some background for us.
We have the technology to upload millions of cat videos; why not make a service that helps us care for our aging (and growing) geriatric patient population?
“To dump” has one more definition, usually used in the digital world, and I think it’s actually quite apropos to what I’ve proposed: “a copying of stored data to a different location.” 
Anyone want to build it?
 
 
Graham Walker is an emergency physician in San Francisco, and the developer of several web-based medical tools: MDCalc, a medical calculator, and theNNT, an evidence-based medicine tool. His monthly column, Emergentology is featured in Emergency Medicine News. You can also find him on Twitter @grahamwalker.

The pain of processing past records

A few months ago I wrote a post about the 159 page digital fax that I received, containing records for a patient’s recent lengthy hospitalization.

I’ve now discovered something even more time-consuming and annoying: a 202 page paper record mailed to me by a major medical system. (I won’t name names right now; suffice to say this system uses EPIC, as do many big medical systems these days.)

Sigh.

And this isn’t even the patient’s entire record. This is just the last two years, per my request; I’d thought this would probably give me enough information to meaningfully assist the patient and his family with the geriatrics issues.

In truth, I’m not surprised at the volume of this record, although I *am* surprised that the health center sent me a massive printout instead of sending me a CD.

Today I share some details, in hopes that it’s helpful to illustrate the state of health information exchange today, and what many primary care doctors have to deal with when they take on a new complex patient.

My workflow for a 200 page set of paper medical records

As Robert Rowley points out in a recent blog post, a modern “paperless” practice is in fact not so paperless.

At my old clinic, where we were still dealing with paper charts, this monster stack of records would have ended up in my box, where the medical records staff would expect me to go through it and indicate which parts to keep. (Guess what kind of chore tends to linger in the PCP’s box for days to weeks?) Then someone would have to punch holes in it and file it into the chart.

Now that I have my 21st century tech-equipped micropractice, here’s what I had to do:

  • Scan all the sheets into my computer and convert to PDF. I use Adobe Acrobat for this. Fortunately, I upgraded my printer-scanner a few months ago, and it scans pages through the document feeder pretty quickly. Still, the feeder can only hold about 80 pages, so this meant three big scanning runs. I did other administrative work while this was going on.
  • Combine the new PDFs into one single file and run OCR (optical character recognition). Sure, there are dozens of small items in there, but it would be too time consuming to create a multitude of small files (even though that’s often useful in the long run). Instead, I make a mega records file and run OCR, hoping that I’ll later be able to search the darn file for the particular info I need.
  • Shred the paper record. God forbid this brick of paper fall into the the wrong hands, or onto the toes of the person with the wrong hands. It must be shredded. (Same goes for those lab report copies that I get via snail mail, even though the info was already faxed to me.) Unfortunately for me, the shredder in my home office does not do 80 pages at a time; it can only manage 12-13 pages. So shredding the record is not a trivial step. I think about trees as I watch reams of paper get munched into little bits. Since this activity, unlike most of my clinical work, does not require much mental or emotional attention, I wonder if this counts as a moment of cognitive restoration. (It might, except I’m a little annoyed at having to do this in the first place.)
  • Read through the record & take notes on the key findings. This part took about an hour. This patient has had many many encounters over the past two years, as well as a few hospitalizations. The records, of course, came with no table of contents or summary of what was inside. They were, however, in chronological order. Interestingly, many pages contained completely useless (to me) lists of what a given clinician had ordered. Please. I don’t need documentation of the orders, I just need the results. (You can leave it to me to infer that the tests were ordered.)
  • Share the records file with the patient via the my EMR’s portal system. In this case, the sharing is effectively with the patient’s adult child since this very elderly patient has poor memory and can no longer manage his healthcare. Although I haven’t been asked to take this step, I tend to share most documents that I file in patients’ charts. (Why don’t I share everything? Because it’s an extra step, because those steps add up timewise, and because I have to remember to do it.)

We should make health record reviewing and sharing easier

I don’t think anyone seriously disputes this, but I do wonder when it will materially become easier, and whether there aren’t a few small steps that the big players could take to make this situation more manageable for docs like me.

In general, the obtaining and reviewing of records remains a pain because to date most healthcare providers haven’t felt very motivated to make it easy for others to view their work, whether those others are clinicians outside their health system, or patients themselves. There are also legitimate concerns about protecting patient privacy and sensitive health information.

Once information is actually pried out of a health provider’s system, one is left with significant issues related to organization and usability. So the next step beyond sharing the information would be to make it easy for others to organize and act on the information.

For information released to patients and caregivers, this means the data needs to be presented in language suitable for the lay public, and not solely organized according to the conventions of those with clinical training. For information released to other clinicians, the data would ideally come ready to easily import into other EMRs.

This is, I hear, could eventually be achieved via things like SNOMED and HL7. Then again, I’ve been hearing about these standards for years and somehow my clinical experience remains dominated by reams of printed pages coming to me by fax and by mail.

Is there any relief on the horizon for the average clinician?

Ideas for better health information retrieval

Let me start by saying that I am absolutely lacking expertise in this arena. Still, I’m going to float a few ideas:

  • Digitize the information request process; make it more transparent and followable. Right now, for either an outside clinician or a patient to request information, you need to fax a release of information to a provider’s medical records office. Once you fax, you have no idea whether they received it, unless you call. Furthermore, some medical records departments answer their phone, but many do not. This is a major drag for medical assistants all through the country, and for those clinicians who practice entirely solo as I do. If we could just submit requests electronically and follow the progress online (why can’t one check the status online?), this would make life easier, and would make it easier to track and improve the health records request process.
  • If a medical center must send printed copies of the record, include a table of contents. Obviously I’d prefer to receive information in a digital format that is searchable and easier to organize, but if you must send me a fax or mail package, can I please have a table of contents?
  • Let patients download ALL their information to a third party personal health record of their choice. I’m hoping for a combo of OpenNotes and redesigned Blue Button output, going into a personal health record. And then of course the PHR needs to facilitate sharing data with clinicians of choice. This at least would make it easier for me to access the needed info. (Plus there are many other benefits to patients having copies of their medical records; too many to list in this post.)
  • Persuade EPIC to improve their records output options. Beyond a table of contents, EPIC should provide the records organized by type: primary care clinic notes, specialty notes, ED notes, hospitalizations, labs, radiology. Actually, better yet would be to get the records digitally and have the option of sorting by date versus by type. Maybe EPIC records could come on a CD that not only contains the data, but also executes a little viewing program. (I have received medical records CDs with dozens of PDFs, and it is not fun.)
  • Let outside doctors riffle through a medical system’s records directly, once patient permission has been given. This one, I admit, is very unlikely to happen. Security concerns and all that. But wow, it would be great, although I’d still need an Evernote-style clipper or other tool to snip out the info of interest and add to my own EMR.

Summing it up

The process of obtaining and reviewing medical records from another healthcare system remains slow and painfully inefficient, especially when records are delivered as monster stack of printed paper. It’s ironic that in this digital age we persist in printing out digital files, mailing/faxing them, and then need to re-digitize and upload to a new EMR. It’s also a lot of time and effort for primary care doctors or consultants like myself, who need to review a complex patient’s past medical history.

At the very least, it would be terrific to digitize the request process, rather than having to fax into the ether and wonder what is going on with the request. EPIC and other EMR systems could also do a better job of providing data to outside providers in a format that is better organized (start with a table of contents), and easier to import into a new EMR.

I’d love to see patients gain the right to download all their medical data to their own personal health records, and then be able to share with other clinicians such as myself. 

Reimagining Geriatrics

(Note: This post was first published at The Health Care Blog on Feb 8, 2012, where the editors changed the title to “One Woman Brand: How one Doctor Started Over Again With a New Practice, a New Specialty and a Great New Outlook on Life.” Which sounds zippy but here I am reposting my work with its original title.)

A little over a year ago, I found myself burning out and realized that my
worklife was unsustainable.
I’d
been working at an FQHC clinic, and had become the site’s medical director a
few months before. I was practicing as a primary care doc, trying to improve
our clinical workflows, problem-solving around the new e-prescribing system,
helping plan the agency’s transition from paper charts to electronic charts,
and working on our housecalls and geriatrics programs. 
All
of this was supposed to be a 50% position — plus 5% paid time for follow-up —
because I had two young children that I wanted to have some time for, and was
also working one day/week for a caregiving website (Caring.com).
Needless
to say, this job was taking far more than 55% of my time, and seemed to be
consuming 110% of my psyche. I very much liked my boss and colleagues, was
learning a lot, and felt I was improving care for older adults.
But
I was also irritable, stressed out, and had developed chronic insomnia. And
clinic sessions were leaving me drained and feeling miserable: try as I might,
I couldn’t find a way to provide care to my (and my patients’) satisfaction
with the time and resources I had available.
One
evening my 3 year old daughter looked at me and asked “Why are you always
getting mad and saying no?”
Good
question, kiddo.
A
few weeks later, I told my boss that I’d be resigning my position in 5 months. And
I started trying to reimagine how I might practice geriatrics.
My
current clinical practice, which
I launched last October, is the result of that reimagining.
My goals for a new geriatric practice
Here
were the goals:
  • To keep
    practicing the part of my work that I loved the most    . For me,
    this means person-centered outpatient care with a focus on geriatric
    syndromes and on helping people navigate the medical challenges of late
    life. 
  • To be able
    to promptly meet the needs of patients and families    . It often
    took me days to get back to people in my conventional job, or it could
    take weeks before a clinic appointment was available. I wanted to try a
    more “open-access” approach.
  • To try to
    offer the most help per unit of my time    . Since there is a national
    shortage of geriatricians (currently 4 per 10,000 Americans aged 75+), I
    think it’s important to consider how to best deploy us for society’s
    benefit.
  • To leverage
    technology to better meet patients’ needs, and improve efficiency.     Technology
    allows us to do some things faster and better. I wanted to see how that
    could be used in helping older patients with their geriatric needs.
  • To have
    some flexibility in my day and my week.     Flexibility is very very
    helpful to the working parent, especially when children are very young as
    mine are.
How my geriatric practice works
To
do all this, I’ve relaunched myself as a direct-pay solo micropractice offering
housecalls and geriatric consultative care. Here’s how it works:
  • I offer
    geriatric specialty care that is meant to complement existing primary care    , so for
    the first time ever, I’m not a primary care doctor, I’m a specialist. This
    feels a little weird (it’s a change in my professional identity) but I’m
    getting used to it. Also kind of quirky: I’m a specialist who is mainly
    recruited by families directly, rather than via referral from primary care
    doctors.
  • I charge a
    flat hourly rate for all time spent providing service    , whether
    it’s in person, by phone, by email/secure messaging, coordinating care
    with other clinicians, or otherwise assisting a person with his or her
    healthcare. There is no membership fee or monthly subscription fee. (I was
    inspired by Doctalker,
    which is a full-service primary care practice using this billing model.)
  • I return
    all phone calls within two hours    , and all written messages within
    one business day. Housecalls are available within 1-2 business days.
  • I let
    patients and families decide how much time they want with me    , although
    I do advise them as to what I think is the minimum needed time for the
    issues they want me to help them with.
  • I don’t
    provide care after-hours or on weekends.     I do explain to all
    patients and families that my practice is not meant to provide urgent or
    emergent care, but instead is meant to provide additional support and
    service regarding geriatric issues. I also try to help families really
    understand the medical issues, so that they are better equipped should
    they need to urgently engage other clinicians.
How the new practice is working out
So
far, so good, even though it will take a while for my practice to fill. (My
goal is to get to about 20 hours/week; otherwise I’d like to keep writing about
geriatrics and technology, and I still collaborate with Caring.com and a few
other companies serving the needs of elders.)
The
people who contact me are usually concerned adult-children, or sometimes
geriatric care managers. They like that I provide a comprehensive overview of
the older person’s health, can help them make sense of what the other involved
clinicians are doing, have lots of experience managing geriatric syndromes, and
am available easily by phone. (The home health nurses like that too!)  They also like that I follow-up promptly by
phone on a management plan.
As
for me, I like that most of my time goes to meeting the needs of patients and
families, rather than dealing with insurance, prior authorizations, or too many
other administrative hassles. I also like that I don’t have to manage anyone
else, or be managed by anyone else. However, I still feel I’m part of a team
since I collaborate with other doctors, assisted living personnel, home health
agencies, private caregivers, geriatric care managers, and family caregivers.
As
for Medicare and society at large, I’m sure they don’t like that I’ve opted
out. I understand, I don’t like it either. Until a few years ago I was a big
proponent of Medicare-for-all, so it’s dismaying to find myself having left the
fold.
On
the other hand, I do think Medicare currently makes is absurdly difficult for
geriatricians to focus on just practicing geriatrics, and on creatively
rethinking geriatric care. For instance, with Medicare it’s usually hard to be
reimbursed for phone time, or for care coordination. Opting out is what allows
me to spend as much time as people need when I make a housecall, or when I’m on
the phone with families or with other clinicians.
Instead
of chasing face-to-face visits, and wrangling with the complexities of billing
Medicare, I can often answer my phone when people call me, and I can look for
new technologies that might improve geriatric care.
And
since I don’t have a packed clinic schedule, it’s easy for me to rearrange
things when one of my kids gets sick, or if something else unexpected crops up.
In
short, rearranging my practice has been terrific for me, and seems to offer a
lot of value to those patients who have sought me out (and, of course, are
willing to pay). Over the next year or two, I hope to learn more about how to
use technology to better leverage my geriatric expertise.
And
who knows, if my personal experiment in geriatrics continues to go well,
perhaps more geriatricians will end up being outpatient consultants, rather
than primary care doctors as they customarily are in the U.S. And perhaps
Medicare and the other insurers will find a way to cover the kind of service
I’m now providing.
Summing it up
After
burning out in a more conventional primary care setting, I opted out of
Medicare and launched a direct-pay solo micropractice providing housecalls and
geriatric consultation.
Unlike
most geriatricians in outpatient care, I’m not a primary care doctor. Instead,
my services are meant to complement existing primary care and specialty care.
Because
I charge a flat rate for my time, I’m able to give patients and families as
much of my time as they want. (Patient-centered care!) I also try to use
technology whenever possible to improve efficiency, since this helps make my
services more affordable to patients, and frees me to help more people in the
time I have every week for clinical care.
I
hope that Medicare will eventually make it easier for geriatricians to focus on
practicing geriatrics, and I hope that what I learn in my own practice will
eventually benefit other practices serving older adults.

Tweet and You Might Receive: Social Media, Serendipity, and Process Improvements

It all started with my sending a tweet.

Actually, that’s not quite true. The way it really started was with my frail elderly patient calling me in mid-January, to tell me he thought he had a UTI. But that part of the story is not new and novel; I’ve often had patients contact me with similar concerns.

I did what I usually do: ordered a UA and UCx. (I know, in theory better to check a UA, and if it looks suspicious, send for UCx. In practice, that’s logistically difficult if you don’t have the patient in clinic and aren’t able to dip the urine right then and there.)

The trouble was, the patient had called me on a Friday morning. “Bummer,” I thought, “I’ll probably get the UA on Saturday but the culture might not be back until Monday.”

Sure enough, on Saturday I checked my fax queue and there was a preliminary report: lots of white cells and nitrite in the urine.

High-risk elderly patient with symptoms. He needed empiric treatment started before the urine culture results would be available.

Being the clinical decision-support junkie that I am, I decided to take a quick peek at empiric treatment recommendations on UpToDate.com, where I confirmed that the recommended treatment is TMP-SMX. Unless, that is, there is local resistance >20%.

Or I could prescribe a fluoroquinolone. But, notes UpToDate, “increased resistance is mitigating the usefulness of the fluoroquinolone class.”

Hm. I found myself noticing that choices do, in fact, induce decision-fatigue. (No wonder so many docs just prescribe whatever they’re used to prescribing.)

Clearly, the task at hand — selecting a suitable antibiotic for empiric treatment of UTI — would be much easier if I knew what the local resistance antibiotic resistance patterns have been recently.

So, I decided to call the lab itself, Quest Diagnostics, thinking that maybe they’d be able to tell me about local resistance patterns.

The staff answering Quest’s results line seemed quite perplexed by my inquiry. They transferred me to the microbiology lab in San Jose, where they were equally perplexed. Sorry doctor, your culture results won’t be available for 1-2 days. And *then* we can tell you what the resistance pattern is for YOUR submitted sample.

I kept telling them I’m not asking about my sample, I’m asking about recent resistance on all urine samples from community patients.

I kept being told that resistance results will soon be available for MY sample.

Finally they transferred me to a supervisor, who told me that she sees what I’m getting at, and no, they don’t provide this information.

“But you must be culturing 1000 urines per week,” I pointed out. “You must have a sense of how much resistance there is to certain drugs.”

She laughed. “We run more like 10,000 urines.” But, she went on, this didn’t mean they had general antibiotic resistance data to share with doctors. Instead, she recommended I try the public health office. I didn’t bother to point out that they wouldn’t be open on a Saturday.

I hung up, picked an antibiotic to prescribe, and sent my request to the patient’s pharmacy

And then I sent out a tweet, commenting that although Quest does all these cultures, somehow the resistance data isn’t available to community docs like me.

A tweet heard across the country

To my surprise, my tweet was noticed by another doc, @HenryWeiMD, who addressed a follow-up tweet directly to @QuestDx — something I hadn’t thought to do — urging Quest to help @GeriTechBlog.

A few hours later, I received an email from Henry, addressed to me and someone at Quest, in which Henry introduced me to a contact at Quest and pointed out that if this kind of antibiotic resistance data isn’t yet being made available to community doctors, then it really should be as this would be a “HUGE low-lying apple/big win for public health.”

It turns out that Henry was a Presidential Innovation Fellow, though he’d been very much acting in a personal capacity when he followed up on my tweet. His tweet had prompted someone from Quest to send him a message offering assistance.

A week later, I was notified that my issue had been referred to Quest executives, who would be following up with me.

And then a few weeks later, I finally received a phone call from a very nice Quest VP.

“You’re the first to have asked” 

Yep, that’s what he told me. Which I find a little hard to believe, but it’s certainly possible that this is the first time that such a request has made it up the command chain. (Seems unlikely that the local microbiology supervisor would be forwarding inquiries such as mine.)

But here is what is really really exciting: now that I’ve asked — and miraculously been heard — Quest is willing to work on producing local antibiograms for community clinicians!

Now, it’s not available yet. We’ll have to be a little patient and let them figure out how to do it. It’s one thing to have the raw data, and another to collect it, organize it, and present it to a clinical audience. But if all goes well, eventually community docs will be able to access local antibiotic resistance data from Quest.

Woo-hoo! Smarter antibiotics prescribing, here we come!

Will docs actually use this info? Who knows, it’ll probably depend on how easy it is to access. For instance, if local antibiograms end up printed at the end of every abnormal UA report, I’d expect many doctors to incorporate this into their prescribing decision. However, if one has to call Quest or look it up online, then the information will likely be used less often. Still, better to have such info online rather than not at all.

In the meantime, as someone with a background in quality improvement, I’m intrigued by the twist that social media brings into all of this. In the past, we practicing doctors have not had easy ways to make ourselves heard and noticed. Now we can tweet and blog, although if you’re a small fry like me it’s also helpful to get a boost from someone with a little more clout and connections. (Thanks Henry!)

So what conclusions have I drawn from this so far?

  1. Clinicians should be vocal about specific things we need in order to practice according to guidelines.
  2. Social media can connect you to allies and like-minded others.
  3. It helps to know people who know people.

Summing it up

By commenting on a sensible clinical issue — my needing local antibiograms for better empiric UTI treatment — via Twitter, and getting echoed by another doctor with more visibility and connections, I found my request being considered by a senior executive at Quest Diagnostics.

I’m left concluding that we clinicians should be vocal and specific in pointing out things we need in order to practice care according to guidelines or best practices. Social media offers some good opportunities to do this.

I’m also very grateful to the leadership at Quest Diagnostics for engaging with this issue. If they can start providing clinicians with local antibiotic resistance data, they’ll be doing patients and providers a really good, useful service.

Yes, I’m for OpenNotes

Last week, inspired by the VA’s big bold step of going OpenNotes, I wrote a blog post titled “Six Awkward Concerns in My [Not-Yet] OpenNotes,” published on The Health Care Blog.

It was written in the spirit of just about everything I write: to share the nitty-gritty complexities of what I find myself navigating in geriatrics, to bring attention to medical issues that older adults and PCPs struggle with, and to try to bridge the rhetoric-reality gap.

Some seem to have appreciated the post, and the authors of the 2012 study of OpenNotes were kind enough to write a follow-up post on THCB, engaging with the issues I raised. However, it also seems that many perceived my post as casting doubt on the value of OpenNotes, or otherwise unsupportive of the effort to implement OpenNotes as widely as possible.

Whoah Nellie.

So I’ve decided to set the record straight re my position on OpenNotes:

My position on OpenNotes: we should all be doing it

I support the fundamental tenets of OpenNotes and hope that all patients will have access to their notes within the next few years.

To me the great overall value — both ethically and in terms of better health outcomes — of OpenNotes is a no-brainer.

Which is why I didn’t write about whether or not OpenNotes should become the standard of care. Of course it should be. It is, after all, the patient’s information and their health which is at stake, and it’s rather scandalous that for so long it’s been so difficult for patients to access their own medical information.

Furthermore, our historic lack of transparency has often been harmful to patients and families, who far too often are not informed of the diagnoses in their charts. I actually come across this often in practice, both since I see new patients, and because I’m a bit compulsive about reviewing all the problems with patients.

The most common “I didn’t know that” diagnoses that I’ve routinely encountered are dementia, anemia, chronic renal insufficiency, and depression. (Any other clinicians want to weigh in?)

Because of this lack of information, I’ve come across families who haven’t planned for continued cognitive decline (or helped their loved one avoid the psychoactives on the Beer’s list), patients who exacerbate their kidney disease by taking over-the-counter NSAIDs, questionably depressed individuals who never understood why they were given an SSRI and never made sure someone adjusted their dose, and anemic patients who tell me their anemia is new when further chart review reveals that they’ve had chronic anemia for years.

I once had a smart engaged older ex-journalist do a double-take when I mentioned his chronic renal insufficiency. He had a creatinine of 2, which I also found in his hospital records from two years prior. He didn’t recall anyone ever mentioning it to him. And there I was, not anticipating that I’d have to devote half the visit to education about chronic kidney disease (we did after all have several other complaints and issues on the agenda already).

In short, the current state of affairs, in which patients lack easy access to their clinical notes, is a huge problem, since it seriously cripples (sometimes fatally) patients’ abilities to participate in their care and otherwise ensure that their medical care is person-centered and a good fit for their values.

So I say open up the notes! (And the labs. We *really* need OpenLabs.)

Beyond deciding to go OpenNotes: supporting clinicians and patients

Really, the discussion shouldn’t be about whether to open up access to clinical notes. The discussion should be about how to hammer out the details (without spending years dithering or rigorously planning for every eventuality), and how it’s going as we do it. We need constructive conversations about how to make this implementation as successful as possible for patients and for clinicians. My own priorities for opening up clinical notes are that we foster an effective collaboration between patients and clinicians, support patients in being informed about and engaged with their medical care, and ensure that working in an OpenNotes environment feels sustainable to clinicians and doesn’t result in them shirking the documentation of awkward topics.

I emphasize that last point, because I know that primary care in its current form feels unsustainable to many clinicians. (Hence the high burnout rates currently documented in front-line clinicians.) We are asking primary care clinicians to step up, and they should. And they will need support and attention in order to do so successfully.

For example, as is, I already spend too much time charting. Too much, as in way more time than I was given to do it in my previous salaried positions, which is part of why I chronically ran behind and found myself burnt out. Even now, I spend way more time charting than I get paid to do. (Yes, I currently charge by time, and no, I still don’t quite have the nerve to charge people for exactly all the time I spend on their chart.)

I do it because I’m detail-oriented, and because I need my notes to be useful to other clinicians. (I’ve never charted under the assumption that no one other than myself — or a Medicare auditor — was going to seriously take a look, but I can tell you that is not true of many PCPs in community practice.) I also often copy my assessment and plan into the patient recommendations section of my EMR — which means it’s viewable to the patient’s representative — and I’ve been providing patients with detailed written recommendations for the past few years.

For me, I’ve found that is IS extra work, to explain my thinking and suggestions in writing to a lay person. It’s good work, and important work, but it takes time, even when I’m not trying to figure out how to address a particularly delicate topic such as alcohol use.

Now, I care for people who are both medically complex and tend to have a lot of “life” complexities (family issues, home safety issues, dealing with overall decline issues, is this person cognitively capable of making medical decisions issues, coordination between multiple specialists and systems issues, etc).

These patients may not be the ones that most doctors write notes about, but that’s who needs the most medical care, and this population of aging complex patients is growing.

So as we implement OpenNotes, I hope we will collectively commit to regularly checking in with clinicians and with patients, to find out how it’s going for them, and to adjust things as needed to support everyone in doing the work that must be done.

I also hope that those institutions that implement OpenNotes will be willing to share the lessons they learn, as they help their clinicians adapt to a much-needed era of transparency and person-centered medical care.

Summing it up

I’m for wide-spread adoption of OpenNotes. Far too many patients are being currently harmed by inadequate access to and understanding of their medical issues.

I do think many clinicians will need support and assistance in order find the transition to transparency sustainable. I think this will be more of an issue in cases where the patients are medically complex, or when sensitive topics are at issue. We can and should ask clinicians to step up and embrace collaboration, transparency, and person-centered care. And we should plan to support them in this effort.