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Adopting OpenNotes in Sioux Falls, SD: A Case Study

Avera Health is a fully integrated, faith-based health system that includes more than 800 providers in 60 specialties, covering a five-state region. Avera instituted OpenNotes in March of 2014, at the same time they activated their patient portal in MEDITECH, with little fanfare.

Patients and their families, as well as family members and neighbors of Avera providers, were informally polled about transparent medical information and their responses helped guide the decision to adopt OpenNotes. They were asked “What medical information would you want to have access to?” The overwhelming response was “Everything.”

Before the implementation of OpenNotes, patients were able to access their medical information only after submitting a request form to the clinic that indicated in detail what information they wanted. While there was no charge to the patient to access their information, it took the clinic time and effort to select, print and mail the requested materials. With OpenNotes, patients can now log into the portal at their convenience and view almost all of their ambulatory and inpatient information, including progress notes, inpatient history and physicals, consult reports and discharge summaries. Some types of notes are currently not available; for example, pathology reports turned out to be difficult to format in a way that would be useful and understandable for patients, so these are not accessible through the portal. Hospital rounding notes, operative reports, and acute vitals are also not shared through OpenNotes, primarily because providers felt patients would be overwhelmed by the sheer volume of information that often accompanies an inpatient stay. Documentation from allied health professionals, such as occupational and physical therapists, are also not shared through the portal. At this time, access to behavioral health notes is restricted. Avera has also created a “confidential note” that is valuable in circumstances where a proxy user has been established but the patient desires privacy.

Initial resistance to OpenNotes among providers was minimal. The main concern was that there would be “too many questions if the patient reads the notes.” Providers were concerned that patients might misunderstand content in the notes and this lack of understanding would have consequences for patient care. For example, they didn't want a patient to be upset if they saw the word “obesity” in their notes. Providers also worried that patients might be needlessly alarmed by their lab results or X-rays. Thus far, there have been no complaints from patients related to these initial concerns.

At the OpenNotes launch, Avera placed handouts in waiting rooms and sent messages via email to patients to raise awareness of the new service. Providers were alerted to the roll out in town hall meetings, staff emails and conversations with leadership.

Because many Avera physicians were already providing copies of their notes to their patients, it was not necessary to provide formal training on writing transparent notes. Although providers cannot opt out of using OpenNotes, their notes are not available in the portal until they are signed. This gives the provider the ability to temporarily delay a note from reaching the portal if any editing is needed.

To date, approximately 100,000 patients have accessed their medical information through the portal. Patients have not raised concerns about using OpenNotes. In several instances, patients who were reading their notes identified discrepancies, such as surgeries that they'd never had but had been reported in their histories. Their care team was able to quickly correct these errors. Although these situations can be awkward, conversations about errors in OpenNotes typically end well because both patients and providers believe that better information equals better care. Adult children of aging parents have been particularly positive about OpenNotes. If a son or daughter is not able to attend a visit with their parent, they can still easily obtain information about the visit and the care plan through proxy access. Anecdotal evidence suggests that this results in better adherence to instructions.

“Every piece of information regarding our patients belongs to them. Why shouldn't they have access to it?” says Kim Jundt, MD, Chief Medical Information Officer at Avera and a practicing family medicine physician. “We have gradually allowed access to a large amount of information and this has gone unnoticed by the majority of providers. Patients having access to their information is just a normal part of our daily process that we now take for granted.”

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