Q1 2013 Record of Learning by Healthcare Collaborative of Greater Columbus

Patient-Centered Primary Care Collaborative of Central Ohio: Q1 2013 Learning Session – February 22, 2013 TOPIC: Provider-based Patient Engagement Record of Learning Learning Session Objectives As a patient/parent/caregiver….  AWARENESS on value of improving Provider-based Patient-Engagement  EXPLORE promising best practices from around the country -- a good place to start  IDENTIFY commitments to advance patient engagement as a standard of care in Central Ohio Learning Session Materials a) Please click here to view presentation slides and links to videos (url: http://issuu.com/ahcols/docs/2013q1-presentation?mode=window&viewMode=doublePage) b) Logic model used to frame the discussion and identification of best practices

Explore best practice to improve individual care: OPENNOTES

Explore best practice to improve primary care practices: PATIENT PARTNERS INITIATIVE

Key Terms  patient activation: Understanding one’s role in the care process and having the knowledge, skill, and confidence to manage one’s health and health care 

patient engagement: A broader concept that includes activation; the interventions designed to increase activation; and patient’s resulting behavior

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standard of care: A formal diagnostic and treatment process a doctor will follow for a patient with a certain set of symptoms or a specific illness. That standard will follow guidelines and protocols that experts would agree with as most appropriate, also called "best practice.

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local provider-based patient engagement objective: Based on best practices, partner with primary care teams to implement improvements that advance patient engagement as a standard of care in Central Ohio

Record of learning from Q1 2013 session Below is learning from the 95 leaders from business, government, health care and the social sector that participated at the session. Participants worked in small groups and were asked to explore best practices through the lens of a patient/parent/caregiver. •

OPENNOTES: Exploring best practices in small groups Imagine using OPENNOTES as a patient/parent/caregiver in partnership with your primary care team. SUGGESTED DISCUSSION SCENARIOS  PATIENT: reviewing information about me and my health from a recent primary care appointment  PARENT: sharing information with partner from a recent pediatric visit with child  CAREGIVER: helping aging parent make sense of health information and follow-up items

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WHAT is a key reflection from your small-group discussion on OPENNOTES? Blocking sensitive info before MD can speak to patient Challenge-privacy between family members, Opportunity. Ability of caregiver to assist those who are tech challenged Communication, Better informed patients, More engaged in their health outcome Far more opportunities than challenges for stakeholders Gamechanger, alternate to HIE, Improves message heard is message receives, Patient compliance Good idea and access to info. The challenges have to do with privacy, mental health issues, or abuse Greater control over one's healthcare...and better ability to share that information with caregivers Helpful to families How can the record meet the needs of physician to physician communication, patient communication and legal needs without being in conflict Increasing understanding and accountability More positives than negatives Opportunity, Opportunity: Template based writing in lay terms, transparency and access when traveling, moving, etc. Challenges: Dr. writes notes in a way that patients cannot understand, technology/training are not always accessible or accurate, updates and complete notes are not always available. Opportunity: ease of access, transparency, good for all demographics The opportunity to increase patient knowledge, understanding and empowerment Transparency Very helpful for caregivers., patients can take responsibility with information Will help provide better care, save time, and help better understand medicine schedule. Challenges are differing opinions of multiple providers and fraud. What is the potential value of OPENNOTES as a standard of care in our community?

Potential Value of OPENNOTES (% of 20 small groups) High Medium Low 0

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What are the opportunities and challenges of making OPENNOTES a standard of care in our community? Please see Attachment A for learning gathered from small group discussions

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PATIENT PARTNERS INITIATIVE: Exploring best practices in small groups Imagine participating in a PATIENT PARTNERS INITIATIVE as a patient/parent/caregiver with your primary care team. SUGGESTED DISCUSSION SCENARIOS Based on your experiences and observations, what could be better at your primary care practice/doctor’s office?  Potential improvements before the primary care visit  Potential improvements during the primary care visit  Potential improvements after the primary care

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What is a key reflection from your small group discussions on the Patient Partners Initiative? After getting through the opportunities and challenges, ultimately the ROI will be positive in the long run for everyone All staff at the practice must be on board to pay attention to what is and isn't being communicated! It's about helping the patient and wellness...must use a more holistic approach...and listen to the patient Challenging to make the time for this..providers and patients., Opportunity for true patient friendly primary care Communication is key between the patient and all parties in the visit... validation of our concerns Coordination of patient expectations Engages fewer patients without much clinical value Focus shifts to always improving., Common understanding from patient and provider perspective For small practices, time, space and expertise can be a barrier but is worthwhile pursuing. Getting patients ready for visits w pretty visit calls Improvements in patient engagement/compliance, Process improvement, Par, Patient empathy for provider challenges Increase awareness of patient perspective Offers transparency, that in turn, increases communication. Offers better service and a better attitude...which provides better care. Opennotes, Opp notes before and after helps, Creating a safe space for communicating, EVisits are huge but provider compliance is a real challenge. Payment system and coding is not the issue. Opportunity: follow-up with personal call, make sure that scripts are filled accurately, closes the gap of misunderstanding communication. Challenges: results of labs/tests presented at appointments, medical lists is reconciled with OTC drugs. Opps - Education opportunities, streamline admin duties while waiting to see provider, follow up. Challenges - does this improve the dr/pt relationship? Recruiting process for finding patients to participate Update on "Why the wait?", Create culture that the patient is expected to participate, better scheduling, Hesitate to be seen due to the time requirement for the visit (2-3) hours, please arrive 15 minutes early for check in What is the potential value of PATIENT PARTNERS INITIATIVE as a standard of care in our community?

Potential Value of PATIENT PARTNERS INITIATIVE (% of 20 small groups) High Medium Low 0

100

What are the opportunities and challenges of making PATIENT PARTNERS INITIATIVE a standard of care in our community? Please see Attachment B for learning gathered from small group discussions

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WHAT CAN I DO TO ADVANCE THESE BEST PRACTICES? Learning session participants were asked to consider lending their names (see below) to invitations used to engagement primary care teams. OPENNOTES: 67 participants indicated approval to include their names on invitations PATIENT PARTNER INITIATIVE: 64 participants indicated approval to include their names on invitations

Next Steps •

Access HealthColumbus will apply learning from today’s session to shape the final design of improvement projects we intend to coordinate to improve provider-based patient engagement as a standard of care in Central Ohio.

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Access HealthColumbus will communicate progress and learning with leaders from business, government, health care and the social sectors of Central Ohio.

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Access HealthColumbus appreciates the time and learning shared by participants, especially considering the wintry mix of weather we experienced this morning!

Learning Session Participants Please see Attachment C for a listing of leaders participating at today’s learning session

ATTACHMENT A: Small group reflections on OpenNotes

Opportunities Increase health literacy and understanding of key terms for patients Enable access for caregiver (child, spouse, etc.) in order to improve engagement. Parent could be in a different state. Improve pt. communication Caregiver immense benefits: time and place Patient: reminder about visit, take/show another provider so he/she knows, patient become more empowered. Parent: sharing info with school nurse. Caregiver: help alleviate communication gap between patient, MD, family members. Helpful to families. Increase continuity of care. Lower after visit questions from patients. Patients can get own records/shot records. Helpful to parents Transparent Increased engagement Medication coordination of care Trust privacy Reminders – feedback to patients Major opportunity for caregivers to understand patients needs and help them manage their care. Remembering everything you and your physician discussed @ your visit. Keeping meds straight Including other settings like inpatient care could also be very helpful. Patients better prepared for visit. Information is golden. Clinicians like to care for patients who understand what is going on with care. Increases understanding for encounter, aids recall, lowers visit anxiety. If child goes alone – parent has information of visit. Children have positive experience Template based—meds/therapy Transparency and accessibility—military example/vacation Increases the usefulness of notes, loosen documentation standards for payer sources. Reviewing, reminding and educating about care and meds. Improve child’s health literacy. Distractions during visit cleared by reading note.

Challenges Language barriers between phys-patient. Ex: if phys. Has accent. Patient/caregiver interprets info. Different from how it was intended. The language used by MD Timeliness of MD recording Many purposes: learn, med documentation in jargon works within industry, pt. communication (add pt. friendly summary). Are these 3 in conflict Patient: may not understand vocabulary, communication barriers (can’t read), not understanding codes/diagnosis, lock of internet/tech. Lack of technology (for the elderly) Appropriate documentation (comprehension of notes) “sensitive” notes How would it affect medical malpractice? medication reconciliation Knowing all care givers/care givers sharing information Concern about who has access to the information How to provide feedback/reminders to patients Does patient have a computer?! Non “tech-savvy” patients; getting everything set up (password, etc.) and remembering password. Could be initial reluctance from providers who think this will add work (phone calls, etc.) i/t costs?? Difference in adoption acceptance between providers in a practice. Some providers may have to modify their reflections about their patients (if inappropriate) Not every practice has a portal Not every pt has home computer access Pts understanding all the data that comes into the chart. Health literacy Technology—eccentric provider without access to technology Write in layers perspective Dr. write notes in words all patients can understand Technology—training/accessibility

Multiple family members have access to important health info up to date med list. Clear answers—reveals PCP is aware of problems. Ease to care giver—takes away barriers such as language. Saves time—caregiver doesn’t have to talk to doctor. Medicine—structure ??? to take medicines Build up acute care visits Increase knowledge level Increase empowerment of patient Appeal to learning opportunities: repetition, review, history, visual learner. Improve care—not only engage patients but changes doctor behavior. Pressures Dr. to improve communication. Share with ER and other provider “carrying chart in wallet”. Getting good information Ease of access—care plans Transparency Good for all patients Health care- enhanced Provide black and white info of their visit Parent remembering what the doctor said specifically—details Children or parent—can see what parent is supposed be taking/dosing instructions Ability of caregiver to assist those who are tech challenged Motivate patient to make changes Access – understanding, reviewable data Access to data, tracking and recording of information Access to data, tracking of visits, medicine Access to patient instruction and medical decision making for household members—improve support for patient Improved engagement should lead to improved compliance.

Update complete notes Health literacy, understanding technology, “dumb down” notes, concerns about “tone” of notes, access to computers Recording factual yet sensitively ie domestic violence, drug use. Competing family members family dynamics Differing opinion of doctors—different philosophies and recommendations Fraud Security: fear of disclosure, fear of increased malpractice. Conflict with existing IT modules. Use of technology for current elderly—will improve with next generation. Psychiatric situations/emotional situations. Careful documentation—objective what get’s left out Test results viewed before conversation Personal access—low income/aging. Providers side—documentation error (could highlight mistakes) Take longer write out goals Health literacy—shift in how you practice. Technology glitches/understanding Changing the culture for providers and patients Transparency (for provider comfort) Computer savvy? Use with indigent population. Inhibit full disclosure by phys. Privacy issues (i.e. Viagra) Patient offended by note. Comprehension of terms/ technology access Abuse issues/other issues MH HIPAA firewall for access/MH diagnosis issues Payment for allied health providers that assist docs in providing additional info to patients, etc. (bundled payment should include allied providers who are physician extenders to the patients in their care) must be completely funded Access issues some docs must re-frame how they write notes.

ATTACHMENT B: small group reflections on Patient Partners Initiative

Opportunities Arrive 15 min early—prepped to be seen 10 physicians. Update why the wait? Better scheduling Transparency/communication Better service/attitude = improved care Coordination of expectations for visit (20 min vs 1.5 hour visit) Transparency around costs/billing Managing test results so patient knows ahead of visit about results—for instance—glucose, cholesterol Cane even change layouts and designs of hospital/office Pts priorities for QI may be different from ours Get perspectives from the people who struggle most navigating health care. Pts better prepared for visit—what is expected How to shorten wait times (be on time) How to remind pt of their visit. Commitment to do what you are going to do after the visit. Viewing from diff. perspectives Saving resources instead of spinning wheels Meaningful for pts to engage Onlineincreases volume QI more targeted Can you look online to is dr. running late. Ability to ???? question in audience Could ready pts prior to appt. Follow-up/personal call Make sure scripts filled Closes gap of misunderstanding/communication Educational opportunity—take advantage of wait time Streamline admin duties. i.e. swipe of a card to pull up your data. Follow up with every service ?? – open notes would solve this. Customer empowerment/engagement Better knowledge/understanding of challenges of practice Improvement of quality outcomes, pt. experience, and lower cost. Better ROI Competitive advantage

Challenges 2-3 hour commitment. Hesitate to go/be seen get treated, Time to schedule 1-2 selected a true representation of the pt population? Communication to patient expectation around what will take place at visit Get off focus easily Pt’s voice personal problems Selecting right people Realistic expectations for what you will get out of these meetings. Pts expect clinician to solve everything Entitlement mentality of pts. Time commitment needed to implement these changes under current reimbursement system. Rotate pts to keep info fresh—prevent single view Fallout from not implementing perceived important suggestions Does it really change healthcare? Sustainability Finding the ideal patient Results of labs/tests present on appt. Med list reconciliation late. Is it improving the patient/doctor relationship? Better results? Acceptance by provider community Picking the right patients variety and representative with the time commitment Create an open, welcoming environment that offers patient voice and provider ears. Can be intimidating. Time constraints  patient availability Billing barriers—types of visit, planning time. My voice would not be heard Picking the right patient and demographics Be prepared to implement. How vet potential patients to participate. Specialist application? (wait time) PCP advocate Automated phone system menus Technology – what about patients with limited access? Need to retake patients for more perspectives

Fill out records before visit. List questions! Patient brings questions with them. Pre-visit phone calls remind them to bring items. Get labs done before so visit is more productive. Set self-management goal then do follow-up phone call to see how they are doing. Awareness of patients perspective Patient could set the providers perspective/perception The change you’re making is important to the patient. Print out of visit notes/plan of care Perspective of patient of doctors “life” More effective use of patient wait room (on site use of computer to time/see Ease of mind – post visit lab results. Process improvement Higher engagement/compliance Patient empathy for HCP challenges Faster communication – e.g. timely response to phone calls Friendly encounters Technology Ease of care, readily available information, knowledge of pharmacy information Input/intake of front office. Post visit survey Opportunity for engaging less educated patients, good to have wide range of patients. Valuable to practices Electronic value in standardize Q’s and push out info back to pt. Email reminders about visits, med renewal Pre-fill survey on health updates (email forms) Need better triaging of communicating results Communicate in the way that the patient wants. Not one method.

More fluff than substance

Danger of patient opinions without change, manage expectations on change being implemented. Important to have project aim defined and bring patient voice into that. Save space and time and expertise Challenging to meet needs expressed by pts. Lead to frustration. Engaging patients who don’t want to be engaged.

ATTACHMENT C: Listing of Participants Mike Parminder Tim Michael Jon Amy January Jason Douglas Jeff Dianne Melissa Ernie Meggen Greg Michelle Dennis Scott Sue Maria John Carol Shelly Erica Sarah Pat Jill Shane Jerry Eric Teresa John Janel Gretchen Tom Will Jeff Donna Nicole Kathryn Mike Lisa Erin Thomas David Amy Stephanie David John Cathy Un Jung Gail Jenny Kathy Heather

Anthony Bajwa, MD Bangert Barber, MD Barley Bashforth Beach Beaver Bennett Biehl Biggs Bodey Boyd Brown Carroll Chiang Clark Compton Conner Courser Davis Deibel Diodore Drewry Durfee Ecklar, MD Fetzer Ford Friedman Fryxell Garcia Glacken Grover Gunderson Hadley Hancock Harper Hedrick Hemminger Hendricks Hossenlopp Igel Jech Jones Kageorge, MD Kelling Koslki Kubalak Leite Levine Lim Lowe, MSW Lynch Maedeker McCormick

Mount Carmel Medical Group Columbus Neighborhood Health Center COHIE National Church Residences OMA Ohio Department of Health The Ohio State University Wexner Medical Center Preferred Benefits The Ohio State University Wexner Medical Center Access HealthColumbus CEBCO / CCAO Ohio Pharmacists Association The Little Clinic Abbvie Right at Home The Breathing Association - Lung Health Clinic Preferred Benefits Mount Carmel Medical Group The Ohio State University Wexner Medical Center Access HealthColumbus American Health Network Hilliard National Church Residences Home and Community Services OPERS Mount Carnel Health System The Clinic at Faith Misson Ohio Department of Health The Ohio State University Wexner Medical Center Southeast National Church Residences The Ohio State University Wexner Medical Center Mount Carmel Health System Wells Fargo Insurance Services NovoNordisk Duet Health Access HealthColumbus American Health Network Hilliard Otterbein University GlaxoSmithKline Huntington Bancshares Inc. Ohio Academy of Family Physicians The Ohio State University Health PLan Mount Carmel Medical Group KellConsult LLC PBO Abbvie Access HealthColumbus UHCAN Ohio Columbus Public Health CPP The Ohio State University Wexner Medical Center LifeCare Alliance

Margaret Sherri Andrew Eric Sandra Rich John Allen Julie Diane Joanne Malcolm Reginald Mark Mary Jo Matt Mike Pam Patricia Amy Andy Kaitlin Megan Maggie Tanya Krista Nazhat Robyn Steve Andrew Bruce Amy Beth Cheryl Beth Beth Andre Justin Ted Laurel

McDonald McMillan McMurray Megger Mendel Menke Mullins Nichol Owens Oye Pearsol Porter Pryear Ridenour Ruggieri Salts Schaublin Schultz Scott Smith Smith Smith Smith Snow Stamp Stock Taj-Schaal, MD Taylor Toth Vekstein Wall, MD Watson Weinstock, MD Whitmire Whitted Willcott Williams Woods Wymyslo, MD Zulliger, MD

Sanofi The Ohio State University Wexner Medical Center Sanofi GlaxoSmithKline Institute of Holistic Health Careers YourQuest Amylin Pharmaceuticals CeutiCare Nationwide Children's Hospital APS Healthcare Inc. Center for Public Health Practice Access HealthColumbus The Ohio State University Wexner Medical Center The Ridenour Group Institute of Holistic Health Careers The Little Clinic Aetna Anthem Blue Cross and Blue Shield Anthem WellPoint Sanofi Ohio Academy of Family Physicians Ohio Academy of Family Physicians Franklin County Sanofi Access HealthColumbus OSU Gen Int Med Ohio Department of Health Nationwide Children's Hospital Southeast, Inc. Ohio State University Health Plan Village Family Medicine Village Family Medicine Community Housing Network Columbus Neighborhood Health Centers The Little Clinic Ohio TeleHealth Initiative Kroger Pharmacy Ohio Department of Health American Health Network Hilliard