“That's really what it is, co-generation of notes,” said Dr. Joe Boyce, the hospital's chief information officer/chief medical information officer, one of several presenters at last week's Physician-Computer Connection Symposium in Ojai, Calif., during a session focused on using health information technology to promote patient engagement while simultaneously surviving the coming avalanche of patient-generated data. At Heartland, “We have about 100 patients a week writing their own records,” he said. The symposium was sponsored by the Association of Medical Directors of Information Systems.
“Having a 'second pair of eyes' on the medical record can help improve the quality of the information that providers ultimately use to make clinical decisions,” write Erin Poetter Siminerio and Jodi Daniel of the Office of the National Coordinator for Health Information Technology at HHS in a recent blog post at HealthITBuzz.gov, the official blog of the ONC, which funded an open notes pilot project with the Geisinger Health System.
Siminerio and Daniel report the pilot demonstrated that 30% of patient feedback forms were completed and in 89% of cases, patients requested changes to their medication records and in 68%of cases, a pharmacist made changes to the medication list in the EHR based on patient feedback.
Heartland has about 15,000 patients signed up to use its Web-based portal tethered to its Cerner EHR, where they can not only view their records, but also register to receive notifications of pending appointments in text messages or email. The messages prompt them to log into the portal where there's a link to “Confirm your medical information.”
The messages to patients “remind them to go in there and fill out that history,” Boyce said. “We'll do that a maxim of three times. If they don't do this, or only do part of it, fine. The nurse does it as the regular part of check in.”
Once logged in to the confirmation section of the portal, patients can click on a list of data entry options. With “Appointment Questions and Goals,” a blank text box appears for typing in their responses. With “Medications,” patients are presented with a drop box of what the provider believes to be a list of medications, dose, route of administration, whether the patient is still taking them, and a place for comments about the drug.
Other options help the patient review their allergies, immunizations, problems, procedures, preventive care measures and family history.
Only a few patient-initiated changes, such as the patient's preferred name, go "straight into record,” Boyce said. Family histories are typically cut and pasted from the portal into the record with limited editing.
Most other items, such as additions, deletions or corrections to the patient's list of current medications, their problems and immunizations are held in abeyance until they can be “validated” by staff and added to the Heartland record.
“The problem list and the meds we're the most sticky about,” Boyce said. Patients sometimes report they're taking “the blue pill,” which requires further investigation, he said. With problems, “If people say, 'I have low blood sugar,' what does that mean? If they're on meds and the labs support that, we'll put that in. If someone says they have a migraine headache, we don't want that to go through to the problem list unfiltered.”
What it boils down to, Boyce said, is “when do you trust people to give you good data. If a woman tells us she's had a mammogram, we trust them. But if someone says they had a colonoscopy, it may really turn out to be a rectal exam,” so Boyce said they'll ask for some documentation for the procedure.
The ONC officials also write that the Open Notes Project, launched in 2010 by Geisinger, the University of Washington's Harborview Medical Center, Beth Israel Deaconess Medical Center and the Robert Wood Johnson Foundation, “found that patients who were given access to their doctors' notes reported they do better in taking their meds.”
They also point out that the Health Insurance Portability and Accountability Act “provides individuals with the right to request an amendment to information in their record but the mechanism for providing feedback is not yet institutionalized in healthcare the way it is in other industries.”
There's been concerns about patients using computer technology to access medical records but in practice, Boyce said, “People are pretty good about not abusing their doctors.”
“A lot of the fears that doctors have, they just have to get over it,” Boyce said. “This is the wave of the future. We should be advisors and coaches and procedurealists. But the fact is, the computer has the time and good presentation capabilities and we just have to get used to using it.”
Follow Joseph Conn on Twitter: @MHJConn