Transparency at Stanford: Open Notes and Provider Reviews

Problem

•  Lack of transparency •  Poor patient access to information •  Provider anxiety about changes in transparency

2

Learning Objectives •  Recognize the key elements of a physician

transparency initiative and how it can improve patient satisfaction

•  Understand current Open Notes efforts at Stanford

•  Awareness of patients desire for information about their providers and one proactive approach

3

Stanford Health Care

824,000 sq. foot hospital

613 licensed beds

56 operating rooms

1,194,308 clinic visits

9,743 employees

2,556 physicians

StanfordHealthCare(SHC)seekstocare,toeducate,andtodiscoverbyhealinghumanitythoughscienceandcompassion,onepa=entata=me.

26,046 inpatient admits

68,643 ER visits

1,140 interns & residents

66 licensed ICU

beds

Open Notes

5

6

What are Open Notes?

Doctorcompletesclinicnote

Emailno=fiespa=entnoteis

ready

NoteisavailableinMyHealth

Pa=entlogsinandviews

note

Where Are Open Notes?

7

hFp://www.myopennotes.org/who-is-sharing-notes/

What is happening at Stanford today?

•  Patients have a legal right to their medical records

•  Stanford Cancer Center and Primary Care are sharing notes since 2015

•  Stanford Children’s sharing in multiple specialties since 2016

8

Why complete Open Notes offering across Stanford?

•  Improves patient understanding and adherence1

•  Becoming standard of care and expectation

•  Successful experience at Stanford to date

•  Create a unified patient experience at Stanford, based on our experience to date in Cancer Care and Primary Care

9

1Delbanco,2010

Majority of Notes are Shared

10

64%

78%

85%

15%

84%

43%

94%

33%

88%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

0%

20%

40%

60%

80%

100%

Percen

tofN

otesShared

CancerCenter&PrimaryCareNotesSharedOct2015-Oct2016

95%ofnotesaresharedacrossCancerCenter&PrimaryCare

11

UIimprovement

Minority are Read

Stanford Patient Response

12

1,803responsesforMyHealthusersatpoint-of-service(CancerCenterpa<entsDecember2015–April2016)

Open Note are “useful” to 95% of Stanford Cancer Center patients with MyHealth

5%

18%

26%

51%

How often are Visit Notes by your Care Team in MyHealth useful to you?

Never

Sometimes

Usually

Always “It’spreIysimple.IknowI’mapa<entandmydoctoristhinkinginmedicaltermsaboutme.Seeingmynotesonlinemademetrustmydoctormore.”

-CancerCenterPa<ent

Stanford Physician Experience

•  “We thought there would be many inquiries from patients asking us to explain aspects of the notes, or correct details and inconsistencies, but the actual number of these was very low, and most providers didn’t notice the change.” – Dr. Joel Neal, Oncology

•  I’ve had two trivial episodes where patients wanted the language of our discussion revised but otherwise uneventful. That said, I am happy to write my notes more tactfully and in plain English.” – Sang Chang , MD, Primary Care

13

MD Ratings

14

15

ofinternetusersaresearchingforit.

Source:PerformanceInsights,TransparencyStrategies:OnlinePhysicianReviewsforImprovingCareandReducingSuffering,2014PressGaneyAssociates

59%American adults find online ratings to be

an important consideration when choosing a physician.

(Healthgrades.com, Vitals.com, Consumer Reports, Yelp…)

Provider Ratings

Consumerism Driving Online Physician Ratings

Source:SoSwareAdvice,“Pa<entUseofOnlineReviews–2014”

Whenpa+entssearchMostValuableInforma+ontoEvaluatePhysicianPerformance

[CATEGORY

NAME],[VALUE]

Toevaluatecurrentdoctor,20%

[CATEGORY

NAME],[VALUE]

Physicians Have Web Presence Whether they know it or not…

Dr. Coutre Hematologist

Dr. Mell Vascular Surgeon

Dr. Rizk Pulmonologist

Dr. Weinacker Pulmonologist

Dr. Welton Colorectal Surgeon

Nodata

Nodata

Nodata Nodata

Why Post MD Ratings & Comments Online?

Easyaccesstopa=entfeedbackforpa=ents/familiestosa=sfytheincreasingconsumerdemandforhealthcarera=ngs.

Posi+vemarke+ng&increasemarketshareforStanfordHealthCarephysicians(99.6%have>4stars).

ProvideStanfordHealthCarewithvisibility&controlofweb-basedra+ngsofourphysicians,ratherthandefaul=ngtosta=s=callyinvalidthirdpar=es(Healthgrades.com,Vitals.com,etc.).

IncreasedtraffictophysicianprofilepagesandotherSHCsites(MakeanAppointment).

ImprovedScores:Physicianscoresgofrom~17%intop10%à~40%intop10%.

SHC’s Web Presence - Google Fall2014 December2016

SHC’s Web Presence - Stanford MD Profile

Steps Along the Way

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Process&Technology:Collectandunderstand

pa+entra+ngs&comments

•  Definetheprocessandrulesforpublishingra=ngs&comments.

•  Captureandanalyze

•  ~24,000MDcommentsreviewedto-date.

Educa+on&Communica+on:

Conductroadshowstophysiciangroups

•  Communicateprocessandrulesforpublishing.

•  Offerphysiciancoachingandotherassistance.

Transparency:GoLivewithnewPhysicianProfiles

Governance:Implementappealsprocess

•  Launchedstarra=ngandcommentsonphysicianprofilewebpages.

•  Establishgovernancegroup.

•  Developguidingprinciplesandcriteria.

Addressing MD Concerns

“Wewillbecri+cizedifwedon’torderun-warrantedtests.”

Concerns Mi+ga+onStrategies

•  Exclusioncriteriadeveloped

•  MD’swillhavetheopportunitytoreviewcommentsbeforebeingpostedpubliclyandanappealprocessisavailabletodisputecommentsgoingpublic

•  ServiceExcellenceoffersfurtherdataanalysisfortargetedimprovement

•  1:1MDcoachingavailable

“Reputa+onswillbeharmed/shamed.”

“Thiswillhurtphysicianmorale.”

Comments Review & Physician Appeals MD’sreviewcomments

monthly&submitanyappeals

•  ServiceExcellenceteamensurescommentwillnotbepostedonlineinpartnershipwithDigitalSolu=onsteam

Appealrequestsreviewedatweeklywith

ServiceMedicalDirectors

• Asupermajorityvoteisrequiredtoapproveordenyappealsrequests.• Theeventualdecisioniscommunicatedtothephysicianwhorequestedtheappeal.

MD’scanrequestasecondary

appealiftheydisagreewith

decision

• MD’scanprovideanyaddi=onalcommentaryinwri=ng

• Supermajorityvoteisrequiredtoapproveordenyasecondaryappeal

Guiding Principles & Difficult Appeals Inordertoincreasephysicianrecep=vity,weintroducedguidingprinciplestociteforapprovingappealsdecisions.

•  Askyourselfhowwouldyoufeelinthesitua<on?

•  Werethereextenua<ngcircumstances?(havesitua<onalawareness)

•  Wasthecommenttakentoheartanddidtheproviderputthoughtintoit?

•  Didtheylookintoit,addressit,and/ormakechanges?

•  Canwetaketheprovider’swordatfacevalue?(nohesaid,shesaid)

•  Dotheyrememberthepa<entorrecallthespecificvisit?

BeEmpathe=c RecognizePassion HaveTrust

Someexamplesofdifficultappealsrequests:•  “Ididn'thaveconfidencehewasdoingthingscorrectly.”•  “Doesapoorjobofexplainingall(repeatall)op<ons.”•  “Lackofknowledgeofmycondi<onandunwillingtolearnmoretohelpme.”•  “ThedrugsheprescribedhadsideeffectsthatIexperienced,wishshehadtoldme.”

Results by the Numbers

25

Pre-2011 By2015

Likelihoodtorecommend(LTR)Inpa+entß à

ß à

ß à

ß à

EmployeeEngagement

Loca+onsforManagementRounds

LTRCancerCenter

89thPercen=le

75%

216

90thPercen=le

63rdPercen=le

61%

62

22ndPercen=le

MD Star Ratings Comments

Whatpa+entsaresaying:

85%of“careprovider”commentsareposi+ve.

“DoctorPerezismybestguardianangel.Hehelpsmetosurvivemyseriousillness.Hesowonderful.”

“Ihavetotravel41/2hoursonewayforofficevisits,yetIs<lldoitbecauseITRUSTYOUWITHMYLIFE.”

“Doctorwitha"heart."Amazing,compassionate,smartandkind.Deeplytouchedbyher.”

Thank You!

Questions & Answers