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The New Frontier

February 21, 2011
by David Raths
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With Prodding from Meaningful Use Requirements, Providers are Starting to Think About the Type of Tools They Will Need to Engage Patients and Caregivers

Hospitals weigh the impact of PHRs, portals, patient-entered data, and remote monitoring on clinical workflow

One focal point of healthcare reform involves improving transitions in care settings, particularly to the home. Alternative reimbursement and care delivery models such as accountable care organizations are expected to require more patient self-management tools and remote monitoring devices. Meanwhile, Stage 2 of meaningful use is expected to raise the bar considerably in terms of how and when hospitals and physician groups must make patient data available.

The regulatory focus on patient and family engagement is combining with other market drivers such as the increase in the incidence of chronic disease and provider staffing shortages to create new opportunities for efforts to implement patient portals, home monitoring, secure messaging, and telemedicine solutions.

Although many providers are enthusiastic about putting the patient at the center of the e-health equation, others are struggling with both the potential cultural changes and prioritizing it as an IT investment with so much else on their plates.

Christine Bechtel
Christine Bechtel

There has been a surprising level of pushback from some provider groups concerned about sharing patients' own data with them, notes Christine Bechtel, vice president of the National Partnership for Women & Families, and a member of the meaningful use workgroup of the federal Health IT Policy Committee. “I think it is ludicrous to have to state the obvious: It's the patients' data being shared to improve their care,” she says. “For a long time, we have asked patients to become more engaged in their own care. They can't do that without access to this information.”


Patricia Flatley Brennan
Patricia Flatley Brennan

Bechtel believes certain proposals for Stage 2 of meaningful use could have a huge impact. The first would give patients the ability to view and download relevant information contained in the longitudinal record, which has been updated within four days of the information being available to the practice. Another would require 20 percent of a provider's patients to use a secure portal. Bechtel expects more pushback on that requirement, because providers say they can't force patients to use the portal. But she stresses that experience from the field suggests that the percentage of patients using a portal is strongly driven by the leadership of the clinician. Some practices see 70 percent usage by one clinician's patients and only 10 percent by another's. “This should be a no-brainer, a lay-up,” she says. Bechtel believes once providers and patients start using these technical capabilities, they will both begin to see improvements and efficiencies from their own perspective.


Driven by meaningful use requirements, providers will no doubt prioritize developing highly functional patient portals in 2011. What can the majority of providers learn from those few that have already made patient engagement a strategic priority? Large, integrated health systems such as Kaiser Permanente (Oakland, Ca.) and the Geisinger Health System (Danville, Pa.) have made the most progress, and they report greater patient satisfaction and are starting to identify improvements in chronic disease management.

Another trend that may have an impact on patient engagement is consumerism in healthcare. As consumers with high-deductible insurance plans take a more active role in organizing their own care, “they get a view of the dysfunction in communication between multiple providers in terms of continuity of care and repetitive tests,” says Ryan Smith, assistant vice president of eBusiness for Intermountain Healthcare. “We are starting to have the ability to turn patients into the general contractors for their own health. They can connect the dots if the communication is not happening.”

Over the past few years, Intermountain has developed its own patient/member portal called MyHealth that gives access to labs and imaging reports and allows claim review. Perhaps the most transformative aspect, he notes, has been secure physician messaging. “Physicians were initially skeptical, but most find it actually saves them time,” Smith adds. “It is built into their EMR workflow and is asynchronous, so they can answer messages when it fits their schedule.” (Secure messaging capability is another proposal for meaningful use requirements.)

In part, meaningful use is a step toward the patient-centered medical home. Portals like MyHealth can become the online component of that effort, so that the patient has the same access to data that clinicians do, and the ability to electronically message the care team. “That care team is never all together in the same room, but we can help keep that continuity,” Smith says. “And a care manager can keep on top of alerts out of a clinical system or self-entered data and reach out to a patient with reminders.”


Hank Fanberg, director of technology advocacy for the Irving, Texas-based Christus Health, says patient engagement has been part of his organization's strategic direction for many years. “Prior to the HITECH Act or health reform, we realized we had to move toward more ‘person-centric’ care,” he explains, recognizing the fact that patients with chronic conditions don't spend the majority of their time in inpatient facilities. Christus, which has more than 50 hospitals and long-term care facilities in eight states, is working to support the care-giving process across a continuum of settings, including the patient's home.

How important is technology to that effort? “If we start with the idea of the individual at the center, there are lots of things we can do to leverage technology to support them,” Fanberg says. Patient portals and secure physician messaging can be part of the equation, he says. “We are evaluating the usability and impact on outcomes of things such as diabetes disease management using cell phones.”


Christus is also looking at ways to gather physiological data from monitoring devices and integrate it with patient records so the care team can monitor a patient's progress.

Fanberg notes that provider organizations must work through the cultural issues about clinician acceptance of patient-entered data, as well as how that data fits into clinical workflow. “The technology is the easy part,” he says. “My personal view is we need more acceptance of patient-generated data. You want to know if a patient is using homeopathic remedies, for instance.”

Other providers are studying ways in which telemedicine and mobile technology may help patients get care when and where they need it most. The Wichita-based Christi Health, the largest provider of healthcare services in Kansas, in June 2010 launched a program called Via Christi On Call to study the receptivity of both patients and providers to remote, virtual primary care visits. “This type of Web access is part of our roadmap to redesign care delivery,” says Janell Moerer, vice president for business development for Via Christi, which is affiliated with Ascension Health of St. Louis. Early results suggest that an office visit that might take several hours out of a person's day can be completed in 30 minutes online.

Although a patient portal is part of Via Christi's roadmap, Moerer says that more important than doing a portal for a portal's sake is learning which information and services patients and providers would actually find the most valuable.


More health systems are starting to think about how to share data from their electronic health records with personal health records. The 304-bed Lucile Packard Hospital in Palo Alto, Calif., is the first U.S. children's hospital to partner with Google Health on an interoperable personal health record.

CIO Ed Kopetsky says the goal is to improve care coordination, and technology is just a means to that end. Lucile Packard tracks children who are ill and have long-term conditions. Many are repeat visitors who live in other states. “A kid might come for a transplant and then go back to their community and are involved in a care plan,” he explains. “If we lost touch with those patients and their clinicians at home, it puts them at risk. But if parents can better understand their condition and if we can cut down on their uncertainty, it can help improve their ability to adhere to care plans.”

The project is offering families a mobile record of lab results and medications. With the PHR, that record is no longer tethered to Lucile Packard; it is in the cloud, and families can grant access to other care providers. When a health condition changes or a local physician changes medications, that data is captured and carried forward to future clinical care episodes. So far, 60 patients have signed up and Lucile Packard is seeking to understand the most effective way to engage parents. What data is most valuable to them? How closely do they engage with the data and add new medication information? How do community physicians use it?

“As an industry we are still in the infantile stage in regard to PHRs,” he adds. “We need to change the relationship of data to patient. The day I own my own health data is a very important day to me, especially if I have a chronic condition.”


If shared electronic records promise to improve communications with patients, there are still many issues to work through regarding how patient-generated information can be included in care plans.

Patricia Flatley Brennan, a professor of nursing and engineering at the University of Wisconsin-Madison, heads up Project HealthDesign, a national research effort to explore ways to capture and integrate patient-recorded observations into clinical care.

“We would like to change the thinking about a PHR from just another bucket of data to something that helps clinicians see the whole person and enlist people to become active participants in their own care,” she says.

Project HealthDesign researchers have identified several hurdles that must be addressed. Clinicians worry about trusting the provenance of patient-generated data and they have liability concerns about things taking place outside their offices. There are workflow questions about which members of a care team should be paying attention to patient-generated information, and concerns about physicians suffering from information overload.

There are technical issues to work through, as well, Flatley Brennan adds. “Leading institutions such as Cleveland Clinic have worked on ways to feed data from their Epic system to PHRs, but not as much effort has been made on feeding data the other way.”

Although she is excited that there is increased focus on patient engagement and some real dollars behind it, Flatley Brennan cautions that there hasn't been as much interest from the provider side yet. “There is this delightful tension between what technology enables and social change. I would say the jury is still out on this.”

Healthcare Informatics 2011 March;28(3):40-43

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