We sat down with Dr. Scott Fields, Chief Medical Officer at OCHIN, a health information and innovation network serving over 500 organizations and 10,000 clinicians across the U.S. with the technology, research, and expertise to improve health care delivery and integration. Dr. Fields is responsible for providing clinical leadership and guidance to the development, implementation, and management of clinical and health IT systems, including electronic health records (EHRs) and other HIT systems. He is also responsible for the information needs of OCHIN’s clinical research, support, and clinical consulting services. Dr. Fields serves as Professor Emeritus of Family Medicine at OHSU, where he has been a faculty member since 1986. We asked him to speak with us about implementing note sharing in OCHIN’s more than 900 clinics around the country.
How did you get involved with OCHIN?
A clinic I was overseeing in Portland in 1995 became a member of OCHIN. That’s how I initially connected with the organization. I was a practicing physician at Oregon Health & Science University (OHSU), and we had a basic desire to make sure we were serving our entire community, including those who were uninsured or on Medicaid and Medicare.
So, we built an FQHC (Federally Qualified Health Center) and a rural health center there in Portland, and OCHIN provided the best support for those two clinics in meeting federal requirements and reporting needs.
Then seven years ago, I had the opportunity to join OCHIN as their CMO, and I was excited to leverage my work with data and improving care through the use of data in that role.
What was the road to note sharing like at OCHIN? How did OCHIN decide to implement note sharing in all of its clinics?
Well, one of our basic values is transparency and the secure sharing of information, which is where the driving force for sharing notes came from. All of the evidence we could find suggested that sharing notes was good for patients, so the decision to do it was easy. But we’re a collaborative, so implementation is member-dependent. That was less easy. We made the decision to go live in October of 2018, and as of May 2019 all of our primary care clinics are sharing notes as a default practice. We had hoped to implement more quickly, but a lot of concerns were raised by our behavioral health and specialty clinics. So, we decided to go live in all primary care clinics and offer the option for certain specialty clinics to opt out of sharing notes. About 50% of those clinics opted in anyway, which I’m pleased about. We are collecting data on those locations, and we’re hoping that the other clinics will opt in to sharing as they see that it’s going well at those places. I feel good about how far we’ve come in a relatively short amount of time. And I’m ready for us to go all the way, too. We’ll get there; it’s just a matter of time.
How many OCHIN members are now sharing notes with their patients?
We had nine clinics sharing primary care notes in our initial pilot. Now, all of our 115 members on our Epic platform are sharing primary care notes. Currently, even though it’s optional for them, 57% of our behavioral health and specialty clinics are sharing their notes by default as well.
Why do you think sharing notes is important for the populations your clinics serve?
Historically, the most vulnerable populations have experienced difficulty with access to care and quality of care. They’ve experienced a fair amount of discrimination, and that creates a higher level of distrust compared to other populations. The more transparency we can use to demonstrate the quality of care, the more trust patients will have in the care that is provided.
Can you speak about the role of the EHR vendor in sharing notes with patients?
As the philosophy of note sharing expands, it is incumbent upon all EHRs to provide that as a meaningful and technically easy option for clinicians and patients to access. The functionality should be there for health systems and clinicians so that they can easily begin sharing notes with patients and be able to report out on that activity (both what is being shared by clinicians and what is being read by patients). On the flip side, the navigation has to be easy for patients, so they can find their notes with very few clicks once they’ve accessed patient EHR portals.
What’s your own experience sharing notes with patients?
I’ve been sharing notes for over three years at OHSU. We were in the initial pilot group that started sharing notes. I was already in the habit of using Epic’s MyChart to communicate with my patients, and I believed in the importance of increasing transparency with patients, so I was immediately excited about the idea. I know they are reading my notes because they’ll mention it during our visits. I’ve never had any blow-back or need to change my notes. Sometimes patients have questions, or they express frustration about what I’ve written, but those are important conversations to have, and I don’t think we would have them if they weren’t reading their notes. The truth is — patients always have access to their notes. They just have to ask for them. This artificial construct that you don’t have to share your notes with patients is just that — it’s not true. You have to share them if they ask, so you might as well share them up front.
Has sharing notes with patients changed the way you document?
You would think it might, and I know a lot of clinicians are concerned about that, but, actually, I haven’t changed my documentation methods at all. I still need the notes to be for other clinicians and for myself, but it’s also my goal to be transparent with my patients. And like I said, so far, I haven’t had to change my notes. It’s something I might need to consider in the future, but for now, I’ve adopted the strategy of just talking through things with my patients if they are confused or frustrated about anything in my notes. And those instances aren’t frequent, so this feels like a comfortable approach.
Why is sharing notes with patients important to you?
It should be an innate value to want to share with patients. Ultimately, it’s not about technology, and it’s not about risk. It’s about values. I want to make sure that people, clinicians, and health systems are putting patients before anything else. It should get anybody’s blood going. The patient has to come first, and increasing transparency is a big part of ensuring that.