Q: In the meantime, what else is next?

A: (OpenNotes) has implications for patient safety. We're doing a big study to see what errors are picked up by patients; what mistakes are averted. And we have lots of anecdotes along those lines already.

It has big implications for cost and quality and value: The patient who says, 'I did what you said, Tom. I'm doing fine, I feel better, I'll cancel the next visit.' Cancel a few visits, keep people out of the doctor's office, and that becomes a serious money saver if you multiply it by a few million people. So it has big implications for value.

It has implication for medical education. Why shouldn't a young doctor have his notes critiqued by a patient?

But it's not black and white. For example, we're about to send off a paper that shows, if you remind patients to read the notes, they're much more apt to do it than if you don't. Doctors want to be able to hide some notes. Should they be able to hide part of their notes? Patients may want to have part of their notes hidden from their caregivers

Q: Have you found that any physicians are less than forthcoming?

A: That's a good question: Is the note dumbed down? We have no evidence of that. People were afraid it would happen, but we have no evidence that it's happened.

There are fewer abbreviations. (Doctors) are quietly, I think, aiming the note more toward the patient. The example we always give is SOB: SOB to me means shortness of breath. To you it may mean something else. There are abbreviations we use that you don't know. There are words we use that you don't know.

We use the word "dyspnea." It also means shortness of breath. Pretty soon, with new technologies, you'll be able to put a cursor on that word and it will say "shortness of breath".

Q: Talk about the technology angle of all this.

A: The big players are Epic, Cerner, Meditech, athenahealth and folks like that. We've been working with Epic. Epic next year plans to have OpenNotes as the default foundation. If a hospital buys Epic, it will be delivered with OpenNotes in it. That's a big deal for us. And the upgrades, too: every upgrade they have will make it very easy to go to OpenNotes, if you don't have it already.

Epic is going to instruct their customers how to work with OpenNotes. We're working with Cerner, we're working with other people too. Epic says it serves 170 million people. Cerner says it serves 60 million people. That's a lot of people.

The other targets for us are the CMIOs. They become the transformational officers for their institutions. We're working very closely with them because they're the ones who can flip the switch and make it work.

Our hospital has a homegrown EHR. Most people buy them off the shelf or adapt the portal to their own needs. Epic supplies Geisinger; Geisinger doesn't have MyChart, it has MyGeisinger, which is their adaptation of the portal that Epic provides them. Into that, they can build OpenNotes – which they're increasingly doing.

But I want to emphasize: This is not a software package. This is a movement. This is a movement of full transparency. It's a movement to engage patients and enhance communication between patients and those that take care of them.

We're going to target several groups of people. We're going to target CEOs, we're going to target payers. We've talked with ONC. We've talked with the American College of Physicians, who are advocates for this. We talked with provider groups of all sizes. We try to allay they fears: Try it, you may like it.

We'll also put pressure on from the consumer side. Consumer Reports has written about us a lot, and we work with them closely. We work with the AARP. We're meeting with the Alzheimer's Association next week.

Q: What are some other things you've noticed as OpenNotes has spread?


A: There will be pressure on and among the providers, I think. Another thing that happens is competition. In three parts of this country we've seen a fascinating phenomenon. In Portland, Ore. and Seattle, and in the middle of Pennsylvania, we've seen organizations adopting OpenNotes because the other guy has it.

In Portland, Ore., nine normally-competing organizations got together to work together on OpenNotes; an extraordinary thing. We call it the Portland Consortium.

In Seattle, basically all the big players are doing it, with one other thinking about doing it: University of Washington. Virginia Basin, Group Health, Kaiser Northwest. The only big outlier is Swedish Hospital, and I bet you they'll be doing it within the year. So the word gets around.

The registrations on our portal here are way up since we started OpenNotes. It brings patients to the portal. It keeps patients in the institution. It's a way of both attracting and retaining patients. That's one of the business cases for it.

It's the right thing to do, and there's also a business case as (providers) compete in a crowded market. That's one of the reasons we think we're spreading so quickly.