1. LONG BEACH MEMORIAL HOSPITAL (LBMH) PRESENTED BY J. ENGLAND CONSULTING (JEC) IMPLEMENTATION

2. PRESENTATION OVERVIEW  Introduction to J. England Consulting  Project Proposal  The OpenNotes Initiative  Project Objectives  Implementation Plan  Governance  Project Milestones  Cost-Benefit Analysis  Conclusion

3. PROJECT OBJECTIVES  Achieve Stage 2 Meaningful Use Objective - “Patient Ability To Electronically View, Download & Transmit Health Information” Objective: Provide patients the ability to view online, download and transmit their health information within four business days of the information being available to the EP. Measure 1 - More than 50 percent of all unique patients seen by the EP during the EHR reporting period are provided timely (available to the patient within 4 business days after the information is available to the EP) online access to their health information. Measure 2 - More than 5 percent of all unique patients seen by the EP during the EHR reporting period (or their authorized representatives) view, download, or transmit to a third party their health information.  Increased patient access to medical records Reduction in medical records requests  Improved provider-patient relationship Improvement of patient satisfaction scores by 10%  Increased medication adherence Decreased post-op infection rate

4. PROJECT USE CASE  Current State  OpenNotes Proposal (In Brief)  Future State

5. THE OPENNOTES INITIATIVE OpenNotes is a national initiative working to give patients access to the visit notes written by their doctors, nurses, or other clinicians. It is also a cultural change that is spreading…  Patients have the right to read their notes the doctor or clinician writes during or after your appointment.  Healthcare professionals can build better relationships with their patients, take better care of them and have better outcomes when visit notes are shared.

6. PATIENT AND PROVIDER SURVEY RESULTS FROM OPENNOTES PILOT  Project participants  Primary care physicians affiliated with an urban hospital - Beth Israel Deaconess Medical Center (BIDMC) in Boston  Predominantly rural practices - Geisinger Health System in Pennsylvania  Urban safety-net hospital – Harborview Medical Center in Seattle  Participants were surveyed in Fall 2011 after 12 to 19 months of experience with OpenNotes  Three principal questions  Would OpenNotes help patients become more engaged in their care?  Would OpenNotes be the straw that breaks the provider’s back?  After 1 year, would patients and providers want to continue?

7. THE PATIENT’S POINT-OF-VIEW  82% opened at least one of their notes  Few patients said reading notes made them:  Worried (5 – 8%)  Confused (2 – 8%)  Offended (1 – 2%)  Patients reported important clinical benefit  77 – 87% felt more in control of their care  77 – 85% reported better understanding of their health and medical conditions  76 – 84% reported better remembering the plan for their care  69 – 80% felt better prepared for visits  60 – 78% of those taking medications reported “doing better with taking meds as prescribed”  Nearly 99% wanted continued access to their visit notes  86 – 89% agreed that OpenNotes would be a somewhat or very important factor in choosing a future doctor or health plan Source: Delbanco, Walker, et al, Ann Intern Med, 2012

8. PRINCIPAL CONCERNS OF 105 PARTICIPATING PCPS  85 – 91% stated that “making visit notes available to patients online is a good idea”  When asked about the most difficult aspect, 74% stated nothing was difficult and there was no change in their practice  When asked about the best part, 70% stated strengthened relationships with some of their patients  Not one doctor asked to stop  All three institutions decided to expand the practice widely Source: Delbanco, Walker, et al, Ann Intern Med, 2012 Expectations (%)Post-Intervention (%) Visits significantly longer242 More time addressing patient questions outside of visits423 More time writing/editing/dictating notes3911

9. ONGOING SUCCESS STORIES  Kaiser Permanente Northwest implemented OpenNotes for 1100 providers in April 2014  7,000 notes per day now available to patients  Traffic to portal up 400%  Secure email traffic flat  Rare concerns from patients about care  ¼ of 1% of notes are hidden Source: Chin, H. and Fellows, A., OpenNotes And The Northwest OpenNotes Consortium, HIMSS Conference 2016

10. THINGS TO KNOW  This is not a technical project  System configuration is minimal  It does not drastically impact clinical workflow  Training needs are minimal  It’s a culture change activity!  Clinical leadership is imperative  Communicate, communicate, communicate! This initiative should not come as a surprise to: Providers Patients Support staff

11. GOVERNANCE STRUCTURE  Executive Steering – Sponsors and supports cultural change  Clinical Steering – Chair from each group (IT, Provider, Education, Legal, Marketing) maintains communication and consistent messaging  IT – Technical build and testing  Provider Decision/Steering – Physician champion, physician leaders/influencers  Education – Training development  Marketing – Develop messaging for patients, providers, and community outreach  Legal – HIPAA and sharing of sensitive information

12. IMPLEMENTATION PLAN  Socialization Period  “All Hands” meeting to address concerns  Present data on improved patient outcomes and satisfaction, as well as little/no impact on workload  Explain how individual visits can be “protected”  Encourage discussion and feedback but remain committed to program  Pilot in the outpatient clinics  Full implementation of all LBMC services with upgrade to Epic 2015 in July 2016  Patient and provider satisfaction questionnaires  Key performance indicators

13. PRIVACY AND SECURITY CONSIDERATIONS System configuration should be set to NOT share the following encounter/note types:  Behavioral Health visits  Outpatient clinics feature integrated Behavioral Health services  Any visit for adolescent patients ages 12 – 18  Currently limit MyChart proxy access to adolescent patients  Family Planning visits All current MyChart policies will remain in place  Maintain LBMH Legal and Compliance requirements for MyChart account creation and password reset  Proxy access automatically eliminated on patients’ 12th birthday

14. SYSTEM FUNCTIONALITY  System configured to automatically share notes for designated providers  If provider does not choose to protect the note, upon signing an email will be sent to the patient informing them to logon to MyChart to review note  After Visit Summary (AVS) will include a notification stating, “Your provider’s clinic note will be available on MyChart within 48 hours.”  The progress note will not be available on MyChart until after its creator signs it.  LBMH’s current policy is that all ambulatory notes are signed within 24 hours, but the additional time will create a buffer for any problems that may arise.

15. PROTECTING NOTES The process to “protect” a note is very simple  Click on the Protect button on the top right corner of the note OR  Use the SmartPhrase “.NOSHARE”

16. TRAINING AND POST-IMPLEMENTATION SUPPORT Recommend a mandatory 30 minute classroom training  System functionality review featuring new “Protect” button/“.NOSHARE” SmartPhrase  MyChart sign-up review  Delivery of “How to Protect a Note” job aid Go Live and Ongoing Support  Elbow support will be available in all clinics for the first two-weeks post- implementation  After the first two weeks, support will be available via the EMR help line Patient Support  Patients will be able to sign-up for MyChart at the clinic or through an activation form received in clinic  All active or new MyChart accounts will receive a “How to View Your Visit Note” flyer during registration  MyChart support hotline will be available as usual

17. KEY PERFORMANCE INDICATORS A set of metrics has been defined that will be evaluated on a monthly basis.  MyChart adoption rate  Secure message rates per individual provider  Number of visit notes accessed by patients  Number of times providers chose to not share notes  Patient satisfaction scores  Grievances or complaints received from patients  Patient and provider satisfaction surveys The metrics will be run on prior to pilot implementation to establish LBMH’s current performance

18. MARKETING PLAN - PROVIDER OUTREACH  Communications from CMO/CMIO to providers & staff supporting the program  Post information on the company intranet  FAQs, articles in newsletters  Promote on login screen  Electronic surveys pre- and post- implementation  Elevator speech for steering committee members Source: Open Notes Website: http://www.opennotes.org/toolkit/tip-sheet- launching-your-opennotes-program/

19. MARKETING PLAN - PATIENT OUTREACH  Advertise on local media; billboards, radio, TV  MyChart messaging  Social media  Posters and table tents in waiting rooms  Mailers  Electronic surveys of patients pre- and post- implementation Source: Open Notes Website: http://www.opennotes.org/toolkit/tip-sheet-launching-your- opennotes-program/

20. PROJECT MILESTONES  April 1 – Approval of OpenNotes Policies by LBMH Legal and Compliance Team  May 1 – All Hands meeting and open forum  May 2 – Configuration of all providers within the TEST environment  May 14 – Testing period, including User Acceptance Testing (UAT)  May 21 – Training week  June 1 – Go Live for ambulatory providers  July 1 – Town hall meeting for feedback from end-users and review of metrics  July 15 – Patient and provider surveys sent with results reviewed during second town hall  August 1 – Second town hall meeting with review of metrics

21. PROJECT MILESTONES  September 1 – All facility Go Live  October 1 – All facility town hall meetings with metrics  November 1 – Patient & provider surveys sent with results reviewed during next town hall meeting  November 1 – February 1 – Town hall meetings with metrics  February 15 – Final patient and provider survey during project period  February 28 – Project outcome data synthesized and effort concluded. Decision point for continuation of OpenNotes participation  June 1, 2017 – LBMH re-evaluates printing of After Visit Summary (AVS)

22. COST BENEFIT ANALYSIS  Costs include time of staff to review policies, approve marketing materials and configure Epic as well as consulting fees, and marketing materials.  No additional Epic/MyChart Fee to implement!  Benefits realized through receipt of MU payments, avoidance of Medicare penalties, reduced Medical Records staff by 1 FTE, and anticipated profits from the retention of patients. Return on InvestmentValue Anticipated Benefits $2,062,500 Projected Year 1 Expenses$886,265 Anticipated ROI$1,176,235

23. REALIZING THE VALUE OF OPENNOTES FOR LBMH Source: Chin, H. and Fellows, A., OpenNotes And The Northwest OpenNotes Consortium, HIMSS Conference 2016

24. Q&A