Opening the door to clinicians’ notes

In what promises to be a boon for their patients, UR Medicine and Rochester Regional Health recently kicked off programs offering patients access to some of their doctors’ clinical notes. But could the computerized records systems that make that innovation possible cause headaches?

Officials of both health systems announced the programs at a joint press conference Jan. 10. The two health care organizations, which between them control a lion’s share of the region’s health care, are making the move after each ran months-long pilot programs involving a limited slice of their patient populations.

The programs are part of a national movement led by OpenNotes.org, a Boston-based nonprofit that has promoted similar programs in the United States and internationally since 2010. OpenNotes’ co-founders—Tom Keane, a doctor, and Jan Walker, a nurse—are both Harvard Medical School professors.

The organization’s website describes OpenNotes.org’s mission as a commitment “to spreading the ability of open visit notes and studying their effects. We believe that providing ready access to notes can empower patients, families and caregivers to feel more in control of their healthcare decisions and improve the quality and safety of care.”

“Access to information is critical,” concurs Michael Rotondo, CEO of the University of Rochester Medical Center’s Medical Faculty Group, citing OpenNotes.org research showing that patients who used such access had better health outcomes.

RRH senior vice president Bridgette Wiefling, who heads the health system’s Primary Care and Ambulatory Specialty Institute, similarly agreed, predicting that access to visit notes would help patients better engage in their health care.

The ability for patients to access doctors’ notes comes as a feature of UR Medicine’s MyChart patient portal and RRH’s MyCare portal. Both portals in turn are features of electronic medical records systems installed in the local health systems by Epic Systems Corp., a Wisconsin-based medical software company that accounts for approximately 25 percent of the U.S. market and services most of the country’s large health systems.

In the local health systems’ pilot tests only 2 percent of patients who use the portals availed themselves of the visit-notes feature. Approximately 40 percent of patients access RRH’s portal, Wiefling says. She expects use to increase with the feature’s wider rollout.

The notes feature, which allows patients to view some but not necessarily all of their physicians’ notes, is not a blank check for patients to delve into every aspect of their doctors’ clinical records. Only office-visit notes are available and doctors who do not want to make such notes available can opt out, choosing to block a patient’s access to  notes for a specific visit or for all visits.

Access is so far available only on the local health systems’ websites where it can be found as a feature of patient portals. It is not yet available on either portal’s phone app and won’t be until Epic runs the next upgrades of the health systems’ EMR software, officials say.

UR Medicine’s next upgrade is slated for 2020, says Lauren Bruckner, a University of Rochester Medical Center pediatric oncologist who is UR Medicine’s top patient outreach official.

In a recent New Yorker article, Atul Gawande, a Brigham and Women’s Hospital surgeon, Harvard Medical School professor of public policy and longtime New Yorker staff writer on medical issues whose commentaries are widely read and respected in the U.S. medical community, detailed his own and fellow physicians’ experiences after a recent upgrade of Harvard’s EMR system, which also is supplied by Epic.

Titled “Why doctors hate their computers,” the article describes Gawande’s not inconsequential frustration with EMR.

As a computer nerd who had taught himself to program in his preteen years, Gawande anticipated only improvements and greater efficiency from the upgrade, which was done to put the Harvard medical complex’s medical, billing and administrative functions on a single unified platform. Instead, he found himself blindsided by the upgrade’s mostly negative effects on his practice.

Insofar as EMR systems enhance patients’ ability to track their own medical history and communicate with their doctors, they can be positive for patients, Gawande observed. Still, he found, despite its considerable potential to enhance patients’ experience, Harvard’s EMR deployment has so far turned out to add unnecessary hours to his day and interfere with rather than enhance his patient interactions.

As a surgeon who generally interacts more with patients under anesthesia than in office consults, Gawande thought his negative experience might not be widely shared. So, he checked with Harvard primary care doctors and other specialists as well as with doctors at other large health systems. Many shared his dismay.

An Epic senior vice president acknowledged such problems but attributed them mostly to ancillary uses, a bundling on of features sought by administrators and billing departments that make EMR systems more clunky than necessary for clinicians.

While that would be seem to be a solvable problem, Gawande noted another bug that threw sand in the EMR works, one that has more do to with how humans tend to use digital systems and that could negatively affect programs like the OpenNotes push. Instead of writing succinct summaries as they do with handwritten notes, doctors making digital notes habitually cut and paste previous entries, a habit that often clogs electronic archives with reams of extraneous information.

I asked Rotondo if he had read the Gawande article. He replied that he had. I wondered: Did he see similar problems among the 1,000 or so physicians he oversees?

He paused and then answered: “These systems are evolving.”