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The Beryl Institute invites members to submit posts on patient experience related topics. For guidelines and information on submitting a post for consideration, please contact us at info@theberylinstitute.org.

 

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The Clinician Progress Note as a Tool for Improving Patient Experience

Posted By Jeffrey H. Millstein, MD, Friday, July 20, 2018
Updated: Monday, July 16, 2018

Earlier this year, our practice was asked to become part of a project enabling patients to view our progress notes along with other chart elements via our online portal. My initial reaction to this was curious, and a bit defensive, as was the case for my colleagues at our site. Don’t progress notes belong to us, the providers? Why should we have to share our tool?

In large scale studies, patients report feeling a greater sense of control over their health with this element of transparency. This is a continuation of a national movement toward greater patient autonomy and collaborative care which began with the creation of the “Patient Bill of Rights” in the 1970s. With the momentum unlikely to change in the foreseeable future, the question then becomes: do we resist this, or embrace the change? Making this win-win means re-evaluating the purpose and potential of our notes.

Until recently, I viewed progress notes as serving three purposes: documentation of what transpired during the visit and thoughts on diagnosis and treatment, providing information for colleagues reviewing the chart, and determining level of service for billing. Making shared notes most effective requires reframing our notes as primarily serving the interests of education, improving safety and reinforcing a caring connection. These are already a part of our core mission in patient care, so we can leverage our notes to those ends. They will still fulfill the other traditional goals, but with a shift in priority.

It has been demonstrated that patients often retain little from their office visits, which causes concern about safe adherence to prescribed regimens. Shared notes, along with teach-back, offer a strong opportunity to reinforce clinical plans. It requires adjusting our documentation style a bit, with some effort to avoid language that may be viewed as disparaging, clarify instructions and avoid abbreviations the patient may not understand. I have seen some providers create a separate section at the end of their notes titled instructions, beneath which are clear directions written specifically for the patient. I like to conclude my visits with a reminder, “Mr. X, remember that you can go on the portal and see my notes. If there is anything you forget about our plan, the notes are available for your review.”

There is no question that the EHR is a source of frustration, and a core contributor to clinician burnout. I will not mourn if someday I am able to delegate more EHR keystrokes to another care team member, but I view shared notes as an extension of my connection with patients. I can still view my notes as my own tool, but one which I choose to share in the interest of taking better care of people. Further, if my notes are collaborative in nature, then I can engage my patient while writing them, making the EHR less of a barrier. While there is a little extra up front effort, my patients may be safer and better informed. Who knows? It may even cut down on some after-hours calls and messages. Imagine that.

Jeffrey Millstein, MD is a practicing internist, and physician champion for patient experience at Clinical Care Associates of Penn Medicine.

Tags:  charts  Electronic Health Records  Patient Experience  patient records  providers  transparency 

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OpenNotes: Doctors, Patients and Caregivers on the Same Page

Posted By Liz Salmi, Wednesday, July 19, 2017
Updated: Wednesday, July 19, 2017

After dating me for only 18 months, my now husband became my health care partner. I was 29. He was 31.

In mid-2008, I suffered a massive seizure, landed in the ER, and a scan revealed I had a mass in my brain. Brett suddenly found himself in love with a 29-year-old gal with brain cancer.

After my first hospitalization, Brett jumped into caregiver mode. If I needed clothes for the hospital, Brett packed the bag. When a nurse missed one last stitch in my scalp, Brett finished the job with tweezers. When I needed help coordinating a complex regimen of medications, Brett designed a color-coded spreadsheet that matched my giant pillbox organized by days of the week and times in the day.

Meanwhile, I jumped on the Internet to research treatment options on PubMed, joined Facebook Groups and Twitter communities for people with brain tumors, and started blogging about my experience for family and friends.

There is no right way to respond to illness. My way was to respond with curiosity. I cared about understanding the how and why of my diagnosis and the what of my treatment. Brett’s way was to respond with unconditional love and support. And he cared about taking care of me.

But there is one thing we both needed and continue to need to be active and engaged participants in my care: access to the details of my ongoing care plan—information that is a part of my medical record and embedded in my doctor’s notes.

Brett and I didn’t even know notes were a thing until earlier this year when a change in health insurance forced me to uproot my care from one health system to another. While in the process of collecting my medical records I stumbled across a large PDF document that revealed an insider’s view of my last eight years of living with brain cancer—my notes.

Doctor’s notes (or visit notes, progress notes, clinical notes) are the most important information in our record. This information is readily available to doctors and other members of the health care team to remind them about a patient’s condition and plan for care.

I received great care from my previous health system, but like 96 percent of Americans, my clinical notes were not shared through the online patient portal. This made me wonder… why hide my notes?

I want this to change—for me, for my husband, and for every patient facing a health challenge or working to stay well. 

OpenNotes is a national movement encouraging doctors, nurses, and other health professionals to share the notes they write with the patients they care for using secure, patient portals, with the ultimate goal of improving the quality and safety of care. Shared notes enhance the patient experience by improving communication and trust, and reading notes helps to empower patients to make more informed decisions.

Access to notes can help caregivers like Brett, too. In a 2016 study*, patients and care partners with access to open notes stated that they had better agreement about treatment plans and more productive discussions about their care, and patients were more confident in their ability to manage their health and felt better prepared for office visits. Even better, care partners reported improved communication with patients’ providers at follow-up.

In less than five years, the OpenNotes movement has grown access to notes from 20,000 to over 15 million people. That number is impressive, but it represents just 4 percent of the U.S. population.

When I, the patient, don’t have access to notes, neither does Brett—the person most invested in my care. I spend about two hours each year with my health care team, and over 5,000 waking hours in self-care or “Brett-care.” Access to my notes could help us remember what we need to do between now and the next appointment with my doctor.

So what’s the hold up? Why don’t more people have access to their full medical record and clinical notes?

Doctors and health systems claim people will not understand their notes, or be afraid of what is written in them. This makes no sense to me. I am already looking for information about my diagnosis on the Internet—shouldn’t my first search be based on information in my own medical record?

My husband and I are the most invested people in my care, and the notes are about me. Any information about my health and health care is important to us, and we want to know about it. We can handle it.

* Wolff J, Darer JD, Berger A, et al. Inviting patients and care partners to read doctor’s notes: OpenNotes and shared access to electronic medical records. J Am Med Inform Assoc (2017) 24 (e1): e166-e172.

Liz Salmi is the Senior Multimedia Communications Manager for OpenNotes. OpenNotes is a foundation-funded national movement advocating for clinicians to share their visit notes with patients via patient portals. She is also a patient who does not have access to her notes.

 

 

To hear more from Liz and about OpenNotes, join us August 29th for the upcoming webinar, The Power of Knowing. You will learn more about the OpenNotes movement and how your health system can participate, and hear from a doctor and a patient about their personal experiences with notes and transparency. 

Tags:  caregiver  notes  Patient Experience  transparency 

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Why You Should Take Online Reviews Seriously

Posted By Tashfeen Ekram, MD, Monday, July 17, 2017
Updated: Monday, July 17, 2017

At the root of it, many physicians fear the impact and the effort it takes to manage online reviews. A Harvard study published this year showed 78 percent of physicians believed engaging with online patient reviews would increase their job stress, while a smaller group believed it would negatively affect the physician-doctor relationship. But in today’s digital world, the importance of online reviews is undeniable. After all, a staggering 77 percent of patients visit review sites before choosing a physician.

Healthcare is a Marketplace, and Patients Have High Standards

With the greater emphasis on smart decisions in today’s consumer-driven world, patients have high expectations before they walk through the door. Patients want to know what the experience is like in your practice. Did they read that the front desk staff was warm, welcoming, and thorough? Did they read how you took fifteen extra minutes to help a patient understand a drug’s side effects? Or how the bedside manner of some of your doctors was lacking? The answers are likely yes.

Patients who trust their doctors are more likely to experience satisfaction with them. Seeing a number of online reviews can help patients develop trust with a physician or practice.  Reading online reviews affirms confidence in your patient’s decision. Feeling empowered is a good start for many patients, especially when placed in a new situation, like visiting a referral specialist. Patients simply want a positive healthcare experience.

It’s Time To Be Intentional About MACRA

With the recent adoption of MACRA, the government is prioritizing quality of care. We hear again and again that the goal of value-based care is to lower healthcare costs while improving healthcare outcomes. An article from the Harvard Business Review states, “We must move away from a supply-driven health care system organized around what physicians do and toward a patient-centered system organized around what patients need.”

Unless all your patients have a very close relationship with you, you won’t always know exactly what your patients need—or where you can improve. Online reviews can show you just where your quality of care may be lacking.

What kind of information are patients looking for in your reviews? A statistic showed that 28 percent of patients searched for a practice’s care quality statistics. Star ratings, other patients’ experiences, and doctor backgrounds followed closely in importance. It seems that like the government, patients are looking for information about the quality of care you provide.

Using Reviews to Your Advantage

Online reviews can impact your practice, reputation, and even your relationship with your patients. While they can be a source of anxiety for some physicians, they can also be a tool to boost patient satisfaction and market your practice.  

According to one statistic, 90 percent of consumers read 10 or more reviews online before trusting a business. It’s simple: the more reviews you have, the more patients will perceive you to be credible and trustworthy. And the more they’ll be at ease when they visit you for the first time.

Of course, there will always come a time when the dreaded negative online review happens. The review may be pointing out an actual area of improvement for your clinic, or even something completely arbitrary and out of your control. However, responding tactfully and professionally to negative reviews is just as important as having positive reviews. After all, the internet’s eyes are watching.  

Additionally, there are a few tools out there that help minimize negative reviews. Luma Health is a patient communication platform, which sends text messages asking patients for feedback after appointments. If patients rate the visit an 8 or above, they get redirected to a review website of your choice (like Yelp, Google, Facebook, Healthgrades, RateMDS). If patients rate the visit 7 or below, they’re directed to a private feedback form that’s sent directly to your clinic. This minimizes public negative reviews, allowing you to address matters with patients directly to make it better.  

No matter what the complaint was, apologize to the patient and thank them for taking the time to leave a review. Then invite them for an offline discussion where you can get a better understanding of what they’re really concerned about. Readers—and the unhappy reviewer—will appreciate the openness, helping you build your transparency.

Tashfeen Ekram, MD, is a radiologist, self-taught coder, healthcare innovator and Co-Founder of Luma Health. Contact him on Twitter at @tashfeenekramMD.

 

Tags:  patient satisfaction  physicians  reviews  transparency 

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