We sat down with Homer Chin, MD, MS, an electronic health record (EHR) expert at OpenNotes. He is an affiliate professor in the Department of Medical Informatics and Outcomes Research at the Oregon Health and Science University and a member of the board of OCHIN, a not-for-profit organization that provides information and management services to safety-net clinics in support of the medically underserved. Before his retirement from healthcare administration in 2013, Dr. Chin was the Associate Medical Director for Medical Informatics at Kaiser Permanente Northwest. We asked him to reflect on an illustrious career that merged his love of computers with his passion for medicine.
What motivated you to pursue a career in health care?
That is a good question. When I started at the University of California, Berkeley as an undergrad, I had a hard time figuring out what I wanted to do. After two years, I finally went to a career counselor and took a test to evaluate my aptitude and interests. With my interest in being of service to society, along with my analytic inclinations and interest in science, a career in the medical profession seemed the best fit. I graduated with a degree in bioengineering.
Even in those early days, way before the first personal computer, I had a feeling that computers could be an important tool in improving medical care. After Berkeley, I enrolled in a graduate program in medical information sciences at the University of California, San Francisco, and applied to medical school. The UC San Francisco graduate program was one of the first in computers and medicine. From there I attended Dartmouth Medical School and then completed an internal medicine residency at Santa Clara Valley Medical Center. Medicine was very paper-based in those days. Computer systems were just starting to be used, and medical information was still stored and shared via paper, even though clinicians were able to look up the results of lab tests from a monitor connected to the lab mainframe computer.
How did you come to focus on the early electronic health records?
In 1984, after my residency in internal medicine, I realized that as a practicing internist I could help one patient at a time, but with computers, I could improve an entire system of care and have an impact on many more patients. Subsequently, I entered the medical informatics program at Stanford. After getting my master’s degree in medical informatics, I joined Kaiser Permanente (KP) in Northern California. KP is one of the largest integrated health systems in the U.S., and as such, has great potential for systematizing improvement in healthcare.
In 1993, the Kaiser Permanente Northwest Region (KPNW), based in Portland, recruited me to a newly created position of medical director for information technology. It was the Chief Medical Information Officer (CMIO) role 20 years before the term CMIO was in common use. The CMIO plays a critical role as a leader who understands both information technology and medical care, and who is able to lead a collaborative effort between IT folks and medical providers. Each side speaks a very different language, with very different perspectives, and it is essential to be able to get both sides to understand each other.
When I started, KPNW had a “Results Reporting” system that combined information from the individual departmental systems. That system was able to display a patient-centered view of medication lists, lab results, transcriptions, x-ray, and pathology reports from departmental systems in a Results Reporting mainframe computer. Results Reporting was so useful that there was a push to look at implementing a more comprehensive system–perhaps even computerizing the entire health record. This had not been done before, so we were not even sure it was possible. We sent out a request for proposals, but only two vendors had done enough development to be able to demonstrate their prototype systems.
One of those vendors was a small company in Wisconsin that no one had heard of before: Epic. They were 18 months into the development of an outpatient electronic health record and had it running in a small pilot clinic in Arizona with six family practice providers. We worked closely with Epic to refine their system, and over the next four years were successful in deploying it to all 27 clinic locations in the KP Northwest Region. By 1998, I believe that we were the first large healthcare organization to complete a transition to a completely electronic health record. In 2003, the Kaiser Permanente Program signed a contract with Epic to deploy their system across all eight regions.
Why is it important for patients to be able to access their health records, including OpenNotes?
The thing about electronic health records is that they are just a tool to improve medical practice and safety. An EHR can be accessed in multiple locations simultaneously, improving efficiency. Once you have that functionality, you can provide patients access to their health information, thereby adding a channel of communication that facilitates greater patient empowerment. When patients have access to their medical information, it bolsters transparency, patient involvement, and safety. It allows patients to communicate better with care providers, elevating the overall efficiency and effectiveness of medical care. And, with a patient portal in place, only minimal work is required to provide access to visit notes.
Kaiser Permanente Northwest was one of the first to implement a patient portal in 1996. Patients could see their lab test results, request an appointment, send email messages to their providers, and refill medicines. In 2014, all the major health systems in Portland got together for a meeting to listen to Tom Delbanco and Jan Walker talk about OpenNotes. I had just retired but felt that KPNW was poised to be able to implement this. Mike McNamara, the CMIO of KPNW at the time, was able to convince the clinical leaders of the benefits of OpenNotes, and KPNW was able to implement OpenNotes throughout the region without a pilot. That action helped spur virtually all the other health systems in Portland to do the same. Portland was one of the first cities in the country to make notes widely available to patients. Our estimate is that over 50% of our population has access to their visit notes from one or more health systems in town.
How has technology, specifically EHRs, changed how doctors and patients communicate?
Many doctors feel that the EHR has added to their burden of providing care, and some feel it may interfere with their interactions with patients. However, the EHR is just a tool. If you use it effectively, care can improve significantly. With the increased complexity of medical knowledge and treatments, the computer can embed decision support into the process of care, and clinicians are able to look up information and provide more appropriate diagnosis and treatment. At KPNW, we promoted the sharing of the EHR screen between clinician and patient in the exam room, so that the patient could see what the clinician was doing in the EHR and share in the information. The other big advantage of the EHR is that it allows for greater patient access to information and provides self-service options. Patients can look up test results, refill medications, make appointments online, and now they can also see their complete visit note. This increases communication with their care team, and greatly improves communication between the clinician and the patient.
What are the three greatest EHR challenges we face today, and how can vendors overcome them?
- Making the EHR more intuitive and easier to use.
EHRs improve access to the medical record but are often somewhat cumbersome to use and can take the average clinician more time to provide care than before. The user interface needs to be simplified and improved. Current systems require too many clicks, provide too many options to choose from, and are often unintuitive—making their use onerous. Along with improving the user interface, incorporating some aspects of machine learning could allow the computer to better adapt to an individual clinician’s style of practice and adjust itself to better support that practice.
- Improving the efficiency and safety of medical care.
EHR technology improves transmission in the processes of care (order transmission, results reporting, etc.), but the complexity built into these systems can introduce errors into that process. Current EHRs can introduce errors that are often not obvious. Vendors need to improve ease of use, transparency, and ability to detect and fix unintended behavior. One way to improve EHR safety is to allow users to notify system administrators when the system does not function as intended. That way system developers can correct errors in the system. EHR systems are so complex that it is not possible to test a system fully prior to go-live or in a significant software upgrade. As a result, end-users end up in many respects being beta-testers of the system. Having a persistent and quick feedback mechanism that allows end-users to notify system administrators of perceived errors is critical for improving the safety of these systems. Paying more attention to “fixes” will make these systems safer to use.
- EHRs do not sufficiently leverage the inherent power of computers. Instead, they tend to computerize the previous paper-based processes.
EHRs allow for easy access to information, but that information does not help the provider “synthesize the information” effectively. Instead, the EHR provides a barrage of information, and the provider is often left trying to distill pertinent features and highlight information relevant to a current encounter. EHRs could be re-configured so that relevant information is consistently highlighted and refined to make it more usable in a given encounter. For example, EHRs could default to a problem-oriented charting focus. Current EHRs do not fully facilitate that mode of documentation.
EHRs can also facilitate increased patient involvement and harness patients’ knowledge and interest in their own health condition. Allowing patients to enter their own information into the “subjective” part of an encounter allows for off-loading of up to 25% of a provider’s workload while improving documentation. The advantages of shared documentation were shown more than two decades ago, but few EHRs do a good job of integrating a patient’s interest in their own healthcare. The OpenNotes pilot testing of “OurNotes” is an effort to improve efficiency in healthcare by allowing patients to do some of the work that traditionally falls to the care provider.
EHRs can also implement known “best practices” into their care processes. EHR systems allow for this integration, but the processes to implement and monitor “decision support” are not fully optimized. Better monitoring, tracking, and implementation are required to embed “best practices” into the process of care.
Is there a way we can get competing vendors to work together to put a metric in place that would consistently measure how well practices implement OpenNotes—something that would reliably document when notes are read, and by whom (i.e., patients, and families)?
There are many different aspects to OpenNotes implementation and usage. Therefore, any given metric will emphasize different aspects of usage, depending on the characteristics of a given healthcare organization, and may not be ideal in every circumstance. If the goal is to have an overall measure of OpenNotes implementation, then we should ask to what extent are patients able to access their encounter note, should they want that access. In other words, of all patients seen by a particular healthcare organization, what percentage of patients are able to access their EHR notes if they so choose? That metric would incorporate both the extent to which patients are registered on the portal and the extent to which are they able to access their visit notes.
I posit that the denominator for that metric could be all the unique patients that have been seen in the last year in that healthcare organization. The numerator would be: among those patients, how many of them have, at one time or another, read one or more of their notes? For instance, if a healthcare system saw 100,000 patients in the past 12 months, but only 10% of these patients were registered on their portal, and 90% of the patients registered had read a visit note, then the value for their metric would be 0.1 * 0.9 = 0.09, or 9%. On the other hand, if another healthcare system saw a similar 100,000 patients in the past 12 months, and 50% of these patients were registered on their portal, but only 20% of these patients had read a visit note, then the value for their metric would be 0.5 * 0.2 = 0.10 or 10%. Thus both “percent of patients registered on the portal” and “of those registered, how many are able to access their note” would be given equal weight in the overall metric.
One could come up with many other different ways to measure “effectiveness in OpenNotes implementation,” but I think the above could be a reasonably balanced measure of the effectiveness of OpenNotes in a particular setting.
What is next for you?
Well, I am semi-retired, but I continue to work along these lines of helping people. I am on the board of the Oregon Community Health Information Network (OCHIN), implementing medical tech for the underserved. They are doing work to support information technology and improve medical care in many clinics and practices throughout the U.S. In addition, I am on the board of the Tucker Maxon School, a school that works with the hearing impaired in Portland, Oregon. And much of my time is spent with my sons Maxwell and Alexander, who are still young. I am very fortunate to be able to spend time with them. Watching my boys develop and learning new things alongside them has been a blast!