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Bill Klaproth (Host): Welcome to the ASHRM podcast made possible by the American Society for Healthcare Risk Management to support efforts to advance safe and trusted healthcare through enterprise risk management. You can visit ashrm.org. That's A-S-H-R-M.org/membership to learn more and to become an ASHRM member. I'm Bill Klaproth. On this podcast, we're going to be talking about OpenNotes, and how to protect your organization and how to protect your patients. With me is Heather Marchegiani, Vice President of Operations at Med IQ and Marlene Icenhower, Senior Risk Specialist at Covaris. Marlene and Heather, thank you for your time. It is great to talk with you. Marlene, let me start with you.

So why is this important to healthcare organizations when it comes to OpenNotes?

Marlene Icenhower, BS, JD (Guest): So the concept of OpenNotes was introduced back in 2016, in the 21st Century Cures Act that was signed by president Obama. One of the provisions that was tucked away into that huge legislation was this concept of information blocking or requiring notes to be immediately available. The date that that provision went into effect was April 5th, 2021.

And so right around that time, we had a whole lot of hand ringing and teeth gnashing about this concept of suddenly having notes that physicians were writing immediately available for review and inspection by patients. And as you can imagine, that caused a lot of anxiety. Lots of organizations have already, well by now they have, but they kind of took the lead and implemented those OpenNotes requirement's long before April, and folks are still kind of getting used to them and still fielding phone calls. OpenNotes is here to stay, right? It's not going to go away. So folks, as time goes on, are going to get more and more information loaded into their portals that will be immediately available, and so to the extent that OpenNotes is here to stay, it is a concern and it continues to be a concern among our clients.

Host: So it's here to stay. We better get used to managing it and setting expectations. Heather, let me ask you a question. I know you have a patient perspective on this. Can you share your story with us, please?

Heather Marchegiani, MBA (Guest): Yeah, thank you for having me. So I've actually been in the risk management industry now for over a decade, but it's really my personal story that's most relevant to this discussion and the implementation of OpenNotes. In March of 2021, I underwent a series of five breast biopsies. During that process, I was told to expect a phone call from the radiologist within two to three days, with the results of those biopsies. The very next day, I received an email alert from My Chart and I received one the day before as well, which turned out to be the procedure note from the radiologist. So I didn't really think too much. But when I opened My Chart, I read through the pathology report and found out that I had out of the five biopsies done, four were malignant, one was invasive, three were DCIS.

And so I immediately emailed my OB GYN and she called me in a matter of minutes and she didn't even have the report yet. It was caught up in some triage system. So I ended up reading her the report, and she walked me through what everything meant, which was that I had stage two breast cancer. There's something fairly traumatic about having to read your own doctor, your pathology report. And I'm trying to pronounce words you've never heard before. And knowing what's coming with this type of diagnosis. The irony is this was the very first week that my healthcare system transitioned to OpenNotes.

So, as Marlene mentioned, April 5th was the requirement, but many healthcare systems transitioned to this prior to. I had my biopsies done on a Monday, received the email on a Tuesday. And that very same day, there was another 33 year old woman, same age as me, also a patient of my OB GYN who received the same news on the same day.

And this healthcare system just prepared for how to manage these types of situations. While I wasn't alone in the trauma, it certainly wasn't something that the healthcare system wanted its patients to experience, nor was it something that we, as patients were expecting or, received it particularly well. It was a challenging thing to go through. So this has become a passion of mine to try to educate providers and patients on how this OpenNotes system works and what can be done to minimize the negative impact on patients and how it can actually be used as a benefit to the patient and how the patient can benefit from seeing and being exposed to more of their medical information and how that can positively impact their care and treatment .

Host: Yeah, I could see how disconcerting that was to you to have to read that to your doctor for explanation. And she didn't even have it yet. So Marlene, because of this, have you seen the quality or quantity of documentation go down due to fears of OpenNotes?

Marlene: For the most part, I'd say that the answer is no. I think among our providers, there's always been sort of this understanding that their notes are available for patient to review upon requests. They just have to request them in different ways. Right. So for the majority of providers, the concept of open or transparent notes has really always been in the back of their mind.

Like we mentioned earlier, I think a lot of large healthcare systems and IT platforms have done a really good job preparing for the rollout of information sharing. I know that many, if not most systems, didn't wait until April of 2021 to make these notes available. So a lot of the growing pains, happened in sort of a gradual eased in fashion, which lessened the blow and the impact. I know that our risk management department began fielding calls about this topic, I'd say mid to late 2020. So we had lots of time to prepare. We are seeing providers though be more thoughtful about what they put in notes, but it really hasn't impacted the quality of documentation.

So all the necessary stuff, information is making it into charts. It's just that the language is a little bit different. Interestingly, I have heard concerns from nurses about their notes being available. So right now, nurses notes are not in the category of notes that are open to patients, but in October of this year, they will be. And again, we mentioned earlier that law is kind of, in a rollout phase right now. So in October they will be. So again, you know, I've had to remind nurses that their notes have really always been open and available for review. Then provide them with some of the guidelines, the same guidelines that we're giving our providers about how to write notes.

Host: Right. So Heather being a patient directly impacted by OpenNotes, what would your advice be to healthcare providers and or organizations?

Heather: Yeah. It's an interesting thing, because I think there was a lot of anxiety around this as these systems went live. But I do think there are opportunities to educate patients on what they can expect. I think, my case being that it was the very first day that this was available in the system, I think it caught a lot of people off guard clearly for more than just me. But I think now that we know a little bit more about how these systems work and the impact of them, I think the best or one of the first things we should do is educate the patient on what they can expect, not only in terms of what they're going to see in the record, but timing as well.

If a pathology report could be available in 24 hours, 48 hours, whatever it may be, give them an idea, so they have a better understanding or expectation of what's coming. And certainly that if there's time and it's appropriate, the possible diagnoses that are being looked for as well, setting that stage with the patient early, helps prevent some of the shock and the surprise that may come depending on what comes out of those results.

In terms of documentation itself, whether it be from a visit or an encounter, one of the things that I saw a couple of different physicians through my care, and one of them, when I was reading through the notes that she had written from our very first visit, the very first sentence in there was Heather is a lovely 33 year old patient. That word lovely, made a huge difference in my relationship with that physician. It immediately put me at ease. It gave me confidence that my, you know, the million questions I had to ask, the few tears I might have shed all didn't impact this physician's perception of me. And it allowed me to form a very strong relationship with that oncologist.

And it didn't take a long time for her to write the word lovely or type the word lovely. So I think that's something to keep in mind, just spinning something so simple in a positive way can make a huge difference for the patient and their comfort in their care and treatment moving forward. And then the last thing I'd say, is the patient is responsible for a component of their care and treatment, whether it be follow-up or needing to get a study done, put that in the record and it can be worded in a way that isn't accusatory or creating any sort of, Mao response from the patient, but it allows the patient to feel like they are partially, at least, in control of their own care and treatment.

It was a great reminder for me of the different things I needed to do on my end to follow up in different aspects of my care. And I think a lot of patients feel that way. They, it gives them a sense of control, which isn't something we can always do in the healthcare arena. So those are kind of my three areas that I would recommend for providers and healthcare systems.

Host: Yeah. So those are really good suggestions. And it sounds like knowing that the patient will most likely be reading this, it just makes sense to put language in there that is easy to read and will put the patient at ease. So then on the flip side, Marlene let me ask you this. Are there certain things that providers are reluctant then to document?

Marlene: I'm going to answer it in the converse. Right. Sort of the converse. So there's certain things that they should be reluctant to document. So for example, providers should be reluctant to include judgy or biased or subjective statements. These kinds of flippant remarks about patients' families or even other healthcare providers really leave a bad taste in people's mouth, and leave them with an unfavorable impression about the healthcare team and the care that they received as a whole. These kinds of remarks can also, and if you think about it in strictly financial terms, these kinds of remarks can result in consuming lots of provider and staff time, responding to patient requests for medical record amendments, and telephone time. So even the term morbidly obese now is kind of biased and judgy, right?

So it's better just to, in your note, include a BMI, which says it all, and it's not judgmental. So providers should also be reluctant to engage in professional feuding, pointing fingers at other providers and kind of sniping in the medical record. I think that this is a concept well known to providers, but, folks who do this in the medical record create the impression of unprofessional behavior and poor care. So just a bad idea in general. They should also be reluctant to use weird abbreviations or acronyms. So I think, you know, suffice it to say the days of using the abbreviation SOB for shortness of breath are probably over, right? So sticking to a list of approved abbreviations and acronyms avoids tons of confusion and misunderstanding in the minds of patients, which again, can result in eating up a lot of staff time related to phone calls.

Complex medical jargon, again, not widely understood by patients and will create a whole lot of phone calls. Right? So, using the phrase, for example, cardiomyopathy, just say enlarged heart, everybody, including other clinicians and patients will know what you mean. And I think, you know, what Heather says is really, really important, kindness in the end, including kind supportive language really goes a long way. And it can make all the difference. So, in your charting be respectful, highlight the patient's efforts, their progress, their strengths. It's just kind of amazing to hear what the addition of the word lovely, what the effect that, that had on Heather as she read it.

And so I think remembering the patient in this whole scenario is really important and being kind and respectful. I think that the providers that this has really impacted though, are the pathologists and radiologists. These are the folks who were, and are understandably concerned about patients getting life-changing news without the buffer of a clinician who knows the patient, taking time to explain the result to them.

But on the other hand, these are also the folks who use the most jargon, right? Their entire reporting system is built around jargon. So for our radiologists and pathologists, we recommend, that they change the way they write reports, to make them clearer and less jargony. So for example, the term can not exclude is jargon and it doesn't mean anything.

So instead, the lesion could be malignant. Using active voice, which calls attention to stuff that folks need to do. Right. So instead of saying a lesion was seen, you can say there is a lesion on the upper left lobe. That's active voice and it calls attention. Action verbs and including a timeframe.

So lots of times you'll see in radiology reports, suggest follow-up studies, which is really a meaningless phrase to anybody who reads that report. So instead of that, write something like order a CT scan in the next week. That's direct, it's clear and it has a timeframe. And then like Heather said, pulling out those urgent findings and not burying them in the text of a report.

So describing urgent or important findings first or in bold letters, especially when the report as a whole is lengthy and very dense textually. Taking those findings out and highlighting them are really important. There's some great guidance out there from the American College of Radiology, and the College of American Pathologists about how to write reports and how to soften delivery of these types of reports and what is and isn't acceptable under the Cures Act. The guidelines are really clear, really helpful, and I would encourage folks to look for them.

Host: So it sounds like clear language is really important. Physicians and clinicians should try to avoid jargon and really learn how to soften the delivery, understanding that this is going to go right to the patient. And most likely they're going to be reading it. So, Marlene, have you seen increased patient call volume to hospitals and clinics due to OpenNotes?

Marlene: We have, but I don't think it's been as much as our providers were concerned that it would be. I think this, you know, like I said before, this was one of their biggest concerns is that they'd be flooded with phone calls from anxious, upset patients about, you know, what was in the record or reports, especially from radiologists, and pathologists. But I think the key, and I think they did a really good job of preparing beforehand. The key to minimizing these phone calls is to prepare, not just patients but providers as well. So for example, for providers, providing good documentation training with some of the concepts that we talked about before, about how to use language to convey meaning without being judgemental, harsh or critical. Engaging providers. A lot of the fear that we heard early on was not just phone calls, but it was, I'm going to have to learn how to write in a new language. I won't be able to use my shorthand anymore. There's a lot of research out there that shows that OpenNotes really does not impact workflows. And that when you implement it and you implement it well, it increases patient and provider satisfaction, when notes are transparent because the patient is engaged. So, really terrific resources on opennotes.org about some of the research that's been done in this area. Again, really helpful in engaging providers with this concept.

You know, with patients it's really important, like Heather said, to set expectations ahead of time. So when patients come in, you discuss things like timing, when the note will be available. Some of the reports might not be available or may be available before the ordering practitioner reviews the results. They should also be aware of the possibility of incidental findings, on particularly radiology results and what that means and what it doesn't mean. And some cases patients may want to have the results delayed. And this is perfectly acceptable. It's a request that can be accommodated if the patient requests it. It's also acceptable. And we heard Heather's story about how she got an email about the availability of the report. There's nothing in the Cures Act that says you need to leave those notifications. Right. You have to make the report available, but in some cases it might be acceptable or advisable to turn off the text and email notifications to the patient regarding report availability.

Again, you still have to make the report available, but you don't necessarily have to alert the patient. There's also professional requirements, that are not necessarily known to the patient. So lots of questions that providers ask that seem odd or invasive, but again, they're required to be asked. So the patient understands that you are obligated to assess for things like domestic abuse and suicide. It won't be such a surprise. And then finally just having a great process for managing phone calls and processing amendment requests. Again, there's no requirement in the Cures Act that providers take calls from patients, but you do want to be responsive to their concerns.

So having a really good telephone management program is really important, especially for pathology and radiology. Think about having a script in place that directs patients with questions to call the ordering clinician, if they want to discuss results. And then just having a really streamlined centralized amendment, record amendment process in place. So that these kinds of requests can be processed efficiently.

Host: Marlene, thank you for that. Some really good steps and helping to manage OpenNotes. So we've mainly been discussing, it seems like kind of the shortcomings of OpenNotes. Marlene did provide some positives for us, but Heather, let me ask you as a patient, there has to be something good about OpenNotes. How can you use OpenNotes to your advantage?

Heather: For me, it turned into a tool in my toolbox, throughout my care and treatment. And I think it's important for risk managers and providers to understand how patients will use OpenNotes to their advantage. I think, and I mentioned this earlier, I think patients feel empowered by it. Suddenly they have access to information that they didn't have before readily, without, as Marlene said, requesting it. And being able to go back and look at, for example, your echoes over time and to make sure the ejection fraction hasn't changed or to be able to track their own blood work prior to treatments or after treatments, or just in general, you know, ongoing preventative maintenance of your healthcare. Patients being able to play a more active role in their care means they're going to be more likely to follow up on the studies that are recommended or anything sort of treatment that is recommended for them. And that ultimately is what we are trying to accomplish. That's what the goal of this law was, was to give patients more access to the information they needed so they could obtain a higher level of care, both by being a more active participant, as well as being more engaged with their provider. I think this is while it's going to take some time to get there, many patients are moving in the direction of wanting to be able to see all of this information. And the more that they are able to do that, I think the more engaged patients we're going to have in healthcare system, which ultimately is going to improve their quality of care, and our overall health as a whole.

Host: Well, those definitely are benefits. As you said, patients feel more empowered. People can play a more active role in their care and ultimately, this is there to help increase the quality of patient care. So thank you both for your time today. I just want to quickly wrap up with one last question. Marlene, let me ask you, as we wrap up our discussion on OpenNotes, any final thoughts you want to add about this?

Marlene: I think when it, when it boils down to it, I think, handling OpenNotes and having good systems in place is all about education for the provider, expectations of the patient and engagement from both parties.

Host: Yeah. Excellent thoughts. Thank you for that. And Heather, let's wrap up with you. Any final thoughts you want to add about OpenNotes in our discussion today?

Heather: Just that, and Marlene said this earlier, this is here to stay. And so the best thing I think we can do is to use the system to our advantage, use this law to our advantage and minimize the negative impact. And if we can do that efficiently and productively, I think we're going to have a very positive impact on patient care across the system.

Host: Yeah, very well said. Well, Marlene and Heather, thank you so much for your time today. This has really been interesting and informative. We appreciate your time. Thank you again.

Heather: Thank you very much.

Host: And once again, that's Heather Marchegiani and Marlene Icenhower. The ASHRM podcast was made possible by the American Society for Healthcare Risk Management to support efforts to advance safe and trusted healthcare through enterprise risk management. You can visit ashrm.org. That's ashrm.org/membership to learn more and to become an ASHRM member. And if you found this podcast helpful, please share it on your social channels and check out the full podcast library for topics of interest to you. I'm Bill Klaproth. Thanks for listening.