Providers eye ‘Beth Israel experiment’ on sharing notes

Clinicians at Beth Israel Deaconess Medical Center in Boston are venturing into unchartered territory: They’re posting outpatient mental health progress notes in patients’ electronic medical records so summaries of treatment sessions can be read at home.

The Veterans Health Administration began making patients’ progress notes available via its online portal, My HealtheVet, in January 2013. But most hospitals hesitate to share such notes out of concern patients may misinterpret them.

On March 1, all 15 of Beth Israel’s Department of Psychiatry staff agreed to share psychiatry notes with 10 percent of their ambulatory caseloads – approximately 350 patients – as part of a pilot project to continue the rollout of a digital capability called OpenNotes, says Clinical Director Pamela N. Peck, Psy.D. Then on April 1, the Social Work Department informed about 440 eligible patients billed for mental health visits that their notes were available and about 80 percent opted to participate, says Social Work Manager for Psychiatry and Primary Care Stephen F. O’Neill, LICSW, BCD, JD.

Peck says it’s too early to comment on patient response. Her department is tracking progress and should be able to report the impact of note sharing within a year’s time.

“We left it up to each clinician to determine which of their active patients would be included in the 10 percent for this pilot,” Peck says. “I believe they chose patients who would both value and be safe with reading their notes in real time. We haven’t looked specifically at who comprises these 10 percent. There is much to learn as we continue.”

When Beth Israel along with Danville, Penn.,-based Geisinger Health and Harborview Medical Center in Seattle began sharing primary care doctors notes through the OpenNotes platform in a 2010 pilot study, doctors initially feared their notes could confuse or worry patients and would have to be written less candidly.

They also expressed concern that responding to patient questions would be too time-consuming. But a study published in December 2011 in the Annals of Internal Medicine found 90 percent of patients felt more in control of their care and said they were taking better care of themselves because of note sharing. More than half said they improved adherence to medications. So Beth Israel adopted OpenNotes across the medical center last August, with primary care, orthopedics and rehabilitation services and most ambulatory services coming on board in 2013.

VA patient response to seeing mental health notes has been favorable. In a recent survey of My HealtheVet users, approximately 25 percent of respondents reported viewing their progress notes online. About 80 percent agreed visit notes helped them do a better job of taking medications as prescribed and about 89 percent said they felt better prepared for visits.

Nine out of 10 VA notes users said seeing notes helps them feel more in control of their health care, take better care of themselves and better understand their health and medical conditions and remember their care plan.

Eighty-seven percent of users did not feel that reading notes made them worry more and 88.4 percent of users did not think notes would confuse them more than help.

Patients have always had the legal right to obtain their providers’ notes. Beth Israel’s O’Neill says he has long made it a practice to offer to share his notes with patients and about a third took him up on it in the office.

“The worry that most clinicians have is that, “Oh my gosh, they’re going to misinterpret what I’ve written about them,’” O’Neill says.

Despite having no data on patient response so far, O’Neill says anecdotes from them reveal some surprises.

“We’ve had a number of patients we expected would be so eager to see their notes and really excited by this prospect who have then said, “Gee, no thanks, I really don’t want to look at my notes,’” O’Neill says.

“I do think that in fact it actually speaks to their need to trust us and we are doing well by the secrets that they give to us.”

Some patients are excluded from having access to mental health notes, such as victims of domestic violence who may still be living with a perpetrator. O’Neill adds some staff have asked to ramp up more slowly to adjust to workflow changes.

Providers will be watching what Robert Pierattini, M.D., physician leader of psychiatry at Fletcher Allen Health Care and Department of Psychiatry chair at the University of Vermont College of Medicine, calls “the Beth Israel experiment.”

“If the contents of the note are more subtle, sometimes those kinds of communications are better done in person so you can watch the reaction of the patient, you’re there to answer questions and so on,” Pierattini says.

“But all of that I’m sure can be overcome just by the way the note is written. The clinician will have to be much more careful with communication.”