How Are We Today? Study Lets Patients Help Write Medical Notes, Google Doc Style

(Life Mental Health/Flickr via Compfight)

(Life Mental Health/Flickr via Compfight)

First, beginning about five years ago, came the OpenNotes study. Researchers found that when they gave patients access to their primary care doctors’ written notes, the patients said they got better at taking care of themselves, particularly at taking medications correctly. And contrary to some doctors’ fears, the notes did not tend to cause offense or avalanches of questions.

“OpenNotes” caught on; Some 5 million patients’ records around the country now use it.

Then came the next bold move: The researchers, centered at Beth Israel Deaconess Medical Center, launched a pilot program to open some psychiatric notes to selected patients. (The journal headline: Let’s Show Patients Their Mental Health Records. Our headline: What Your Shrink Thinks.)

And now, the open records movement is moving beyond transparent, to interactive. That is, what if you could not just see your doctor’s medical notes but actually comment on them and contribute to them? As you do, say, when you collaborate online with colleagues on a project in Google Docs?

That’s the next step, says Jan Walker, co-director of the “OpenNotes” project and a researcher at Beth Israel Deaconess and Harvard Medical School. With a new $450,000 grant from The Commonwealth Fund, researchers plan to develop and test “OurNotes,” an interface that will invite patients to contribute to their own medical notes.

Our conversation, edited:

Given the self-obsessive behavior of some people I know who use Fitbits and other health trackers, I think if I were a doctor I’d fear a huge deluge of data into my patients’ health records: “I took 6,000 steps and slept 6:27 hours…” How do you address that?

Jan Walker: One of the frontiers here is making decisions about what data is really paid attention to. As we invite patients to contribute to their records, as we invite patients to upload data from home devices into their records, there are going to be many new inputs of data into the medical records, from technologies that probably don’t even exist yet.

For clinicians, this can look like such a flood of data coming toward them that it’s impossible to pay attention to, to distill it and act on it, and be responsible for understanding everything that’s coming in. So one of the interesting parts of this research is figuring out how to highlight important things for clinicians, and let the rest just be stored.

We will face some of that with this project; perhaps we will be able to have patients flag things they think are important for doctors to see right away, versus just things that are reminders to themselves or things they want to have in the documents.

So will it be kind of like editing with someone on a Google doc, where you can see who did what?

We don’t know yet but we’re thinking about things exactly like that.

What are some examples of uses you imagine?

OpenNotes co-director Jan Walker (courtesy)

OpenNotes co-director Jan Walker (courtesy)

If you’re a patient, you might have gone to the doctor with an infection and been given antibiotics. So you might write down in this record when your symptoms abated or how you did with the antibiotics.

Similarly, you might read in your notes that the doctor reminded you to exercise, and you might keep track of your exercise regime to discuss that with your doctor at the next visit.

Or, in between visits, you may think of things that you want to talk to your doctor about on the next visit, and you would, in essence, set an agenda for yourself so that when you get to that visit, everything gets covered.

And the doctor could look at your agenda beforehand and be more informed, instead of looking things up on the fly?

Exactly. If you can set an agenda before you get to the visit, it gives the doctor a chance to prepare.

Another possibility would be to work with the clinician actually during the visit to write this note. Perhaps the clinician starts the note while you are still sitting there in the office, and you look at what’s being written, you comment, you add, and so it becomes almost a co-authored note.

Yet another use of this interactive feature would be to raise questions about things you think might possibly be in error. Continue reading

Medicare, You Can Do Better (Or Why You Need A Translator For This Post)

By Martha Bebinger

I wrote to Medicare a while back, asking for a price.  I know nothing is simple in the world of health care costs, but I just needed one number, that’s all. One number that Medicare uses, I assume, to calculate payments to doctors and hospitals all the time.

Here’s what I wanted to know: how much does Medicare pay a particular hospital in Boston for a colonoscopy (it was for a story I wrote about searching for the best colonoscopy in our medical Mecca).

The first response I got, at a time when we’re supposed to have more price transparency, was ridiculous.  If I can figure this out, I should be awarded an honorary masters in something, don’t you think?

For the inpatient hospital side:

If you want to calculate a hospital specific DRG payment for a specific fiscal year, look at that year’s IPPS Impact file to get the hospital’s wage index.

Then you can look at Table 5 for the FY 2009 Final Rule to get the relative weights for the MS-DRGs you are interested in. Finally, you can determine the FY 2009 labor related share and non-labor related share rates from Table 1A in the FY 2009 Final Rule.

These files and tables can be found here:

Then the hospital specific DRG payment can be calculated as follows: (wage index x labor related share + non-labor related share) x DRG relative weight.

For the outpatient side:

Medicare Part B data by procedure code for specific years are posted: Data are presented by 5-digit code so you would need to know the code for CT scan and MRI. Code range categories are identified in the readme file which is included in the zipped file.

A colonoscopy for the inpatient side does not affect the MS-DRG assignment. You will only be able to narrow it down by looking at the procedure codes. Below are the two most common reported. Continue reading

The Health Care Cost Runaround: We Can’t Tell You How Much It Is

“The dark ages of health care transparency” is the refined title of WBUR’s Martha Bebinger’s latest post on Healthcare Savvy. I think I’d translate that as, “How the heck are we supposed to try to be ‘value’-seeking health care consumers when we can’t even get simple answers on how much the darned care costs?”

That’s my take, anyway, on Martha’s dark tale of trying to figure out how much some adolescent counseling will cost — and then being told that the information she’s just patiently ferreted out is only briefly valid anyway. We all have stories like this, of endless frustrating hours on the phone with insurers and providers; it’s just that Martha is naturally attuned to the policy implications. To wit:

OK – so I just spent 30 minutes on a series of phone calls to get a price that is only good for the moment? And this is the system in which I’m supposed to be a more “engaged consumer”?

Wait, the folks in state government say, it will get better soon. How? I ask. The state is collecting all the claims made to all the insurers and plans to create a database that we consumers can browse. But here’s the catch. The data will always be old – it won’t be real-time prices. So even when/if this big new database is up and running, I wouldn’t be able to get the price for counseling that I needed last week.

Maine Hospital Price Lists: Everything’s Better Up North


You know how you cross the border into Maine and suddenly the air feels cleaner and the pine trees tower higher? And the big blue sign welcomes you to “The way life should be”?

Turns out the sign applies to hospital price information, too — at least, more than it does in Massachusetts. I happened to be in a York Hospital lobby in southern Maine yesterday, and came upon a notice informing me that under state law, I had the right to ask for a list of the average price tags on all the most common procedures. Very transparent, I thought, impressed. It sure would be great to post that list on WBUR’s Healthcare Savvy social network.

Turns out it’s not so simple, though. I called York Hospital this morning and they haven’t gotten back to me yet, so I tried the Maine Hospital Association. Jeffrey Austin, the group’s vice president and lobbyist, gave me a very helpful rundown of the background on Maine’s price list. Our conversation, lightly distilled:

What’s the story of this price list?

Around ten years ago or so, Maine law was amended to require hospitals to provide the prices of common procedures. But paper lists are something of a “horse and buggy” version of price transparency, and about four years ago, Maine established an online database — run by the Maine Health Data Organization and funded by the hospitals and the health insurers. It’s publicly accessible and interactive, so you can “one-stop-shop” for common procedures. (The “HealthCost” section is here.) Continue reading

Paul Levy: ‘When You Really Let Down Your Team’

The question arises now and then in health care circles: What’s Paul Levy up to these days?

Answer: The former chief of Beth Israel Deaconess Medical Center maintains his popular blog, once called “Running a Hospital” and now “Not Running a Hospital.” He speaks widely on improving hospital quality and safety. And he has just announced that the book he’s been working on is out: “Goal Play! Leadership Lessons From The Soccer Field.”

He writes:

It will come as no surprise to my readers that I have self-published this book, using Createspace.  That service provides a remarkable set of tools to any budding writer.  You can order the book here.  It will be available on Amazon in about a week.

Proceeds will go in part to the non-profit Massachusetts Youth Soccer GOALS program and he asks for feedback at

I confess: Though Paul Levy has many vivid and worthwhile lessons to share from his eight years running Beth Israel Deaconess, I immediately jumped to Chapter 9, titled “I’m sorry” and subtitled “What happens when you really let down your team?”

Paul Levy of "Not Running A Hospital"

After all, his last months at Beth Israel Deaconess were shadowed by a major scandal about his personal relationship with an employee, and though he was otherwise renowned for setting new standards of transparency, many of his readers felt he never gave a full enough account of what happened. Would he now?

I’d give that a qualified yes. If you’re hoping for juicy details, forget it, but he does acknowledge the mistake of “deciding, shortly after I became CEO, to hire a close personal female friend into a new position where she, first directly and later indirectly, reported to me.”

He describes the delayed fallout of that decision and how he handled it, but perhaps most interesting are the lessons he draws. Should there be a formal mechanism to save leaders from their natural tendency to have poor judgment about their own behavior or how it can be perceived? Yes, indeed. He writes: Continue reading

GAO: Health Care Cost Information Tough For Consumers To Obtain

A recent report from the U.S. Government Accountability Office details what many patients already know: when it comes to obtaining information on the cost of health care before getting treatment, consumers are often left in the dark. Here’s what the GAO found:

1. Multiple Factors Undermine Transparency

“Several health care and legal factors may make it difficult for consumers to obtain price information for the health care services they receive, particularly estimates of what their complete costs will be. The health care factors include the difficulty of predicting health care services in advance, billing from multiple providers, and the variety of insurance benefit structures.”

2. Questioning Tests and Insurance Status

“For example, when GAO contacted physicians’ offices to obtain information on the price of a diabetes screening, several representatives said the patient needs to be seen by a physician before the physician could determine which screening tests the patient would need. Continue reading