Columbia St. Mary's Bruce McCarthy: OpenNotes shifts patient-provider power balance

Giving patients a complete look at their health and making them a true partner in the care process were Bruce McCarthy's goals for implementing the OpenNotes program at his facility, Columbia St. Mary's.

"In effect we're saying 'they're not my notes'--really they're the patient's notes, so it changes the dynamic," McCarthy, president of the Milwaukee-based four-hospital system, told FierceHealthIT.

In 2010 the program made its debut at Beth Israel Deaconess Medical Center, with access opening to about 20,000 patients, Today that number has climed to 5 million patients at two dozen organizations.

And it's only just beginning. Earlier this month, it was announced that $10 million in funding is aimed at expanding the program to 50 million patients nationwide.

At Columbia St. Mary's, it was McCarthy's mother who really pushed him toward the OpenNotes program; it has been in play at the health system for three years.

"She was getting older and getting a little forgetful. She lived in another state and I'd call her after her appointments and say 'how'd things go' and she would say 'oh fine, fine.' I knew that wasn't the whole story," he said.

So he would give her doctor, a friend of his, a call to find out what happened during the visit.

"It really motivated me to think 'this is so great for my mom that I can help her with her healthcare, everyone should have this,'" he said.

OpenNotes was the solution.

When discussions began for implementation, there were many physicians who jumped on board, and others who were worried about opening something that, for so long, the patient had not been privy to.

But the core group of leaders who supported the program worked to convince those who were still on the fence about it, McCarthy said. "We used sort of a social movement among the doctors that this is the right thing to do."

And the issues that some of those worries physicians thought might arise? They really didn't.

"It wasn't that big a deal," McCarthy said. "There weren't patients pestering them with questions like they thought there would be. There weren't big misunderstandings about what the [physician] wrote and how they wrote it."

However, that's not to say the rollout was 100 percent problem-free.

"There were some, there were a couple [issues] ... but then when an issue came up, we discussed it broadly and it really sparked great discussions," McCarthy said.

One of those issues was when a physician put what a patient viewed as judgmental information in the note. The note said the patient was being "dishonest" about their medications.

"[W]e used that case to learn 'well maybe we shouldn't be making judgments, maybe we should just be reporting the facts,'" McCarthy said.

Instead of writing that a patient is dishonest, he said, physicians now know to just report that the patient did not indicate that he or she was taking a certain amount of medication.

But problems like that came up "much less frequently than we ever expected," McCarthy said.

For the patients, especially more elderly patients dealing with chronic conditions, the notes were a great help. The patients were better able to track what was going on, remember the discussion and see why a certain point made by the physician was important, he said.

Younger patients are less likely to check their notes, McCarthy said, but those that do also like the option.

"It's like being able to hit the replay button on your visit with the doctor," he said. "It's a living example of a way to make the patient is a partner into their care. If they're a partner, they should be all the way in, we should be working from the same medical record, looking at the same information together."

Many healthcare organizations still are mulling whether or not to implement the program, or maybe are taking their first steps into a pilot. For leaders at those facilities, McCarthy said it's important to talk about it a lot with staff, to get like-minded people together who realize its benefits and "kind of spread the gospel."

Columbia St. Mary's also used a lot of evidence to show that issues would be minimal and return on the program would be high--that included showing physicians articles and studies published on the program.

In addition, the healthcare system first opened notes just to employees. "We turned that on first to test, and it turned out to be not a big deal at all, so that sort of lowered the anxiety levels a bit," he said.

While the Columbia St. Mary's program is fully implemented, on the West Coast UCLA Health just started rolling its program out to parts of the organization this year. Tomorrow we'll publish an interview with Chief Information Officer Michael Pfeffer, examining how their foray into OpenNotes is faring.

Read more on