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BCBS-Tennessee Leaders Make Headway with Medicaid Plan Member Engagement

June 13, 2017
by Mark Hagland
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Leaders at BCBS-Tennessee have been improving Medicaid health plan member engagement in the care management context

On May 2, at the World Health Care Congress, held at the Marriott Wardman Park Hotel in Washington, D.C., Frances Martini, R.N., and Katrina Miller, M.D., presented a session entitled, “Consumer-Centric Care: Member Engagement and Retention Strategies for Complex Populations,” as part of the Medicaid & Health Policy Summit and Behavioral Health Summit tracks, at the Congress.

Miller is chief medical information executive at L.A. Care Health Plan, a health plan that serves primarily Medicaid recipients in Los Angeles County, California. Martini is director of integrated population health at BlueCare, the Medicaid division of the Chattanooga-based Blue Cross Blue Shield of Tennessee. BlueCare manages the care of about 600,000 individuals, out of the total of 3 million BCBST members. At their presentation, Martini and Miller discussed the complex and manifold challenges of managing the care of, and attempting to improve the health status of, a population that is beset by problems of poverty, housing instability, food scarcity, behavioral comorbidities, and general instability around the personal and socioeconomic factors of life, while also attempting to engage members of that population around their health. Yet both L.A. Care Health Plan and BlueCare have been making significant strides in managing the care of their Medicaid plan members, and in engaging them around their health concerns.

Recently, Martini spoke with Healthcare Informatics Editor-in-Chief Mark Hagland regarding recent initiatives and developments at BlueCare in Tennessee. Below are excerpts from that interview.

Qualitatively speaking how might you characterize the Medicaid population that you and your colleagues help to manage at BlueCare?

I would tell you that 60 percent are children. Of the adult population, many are pregnant women. We also have developmentally disabled adults, and adults with significant complex illnesses. And 40-50 percent, especially the high-risk population, also has behavioral comorbidities, which adds to the complexity of their care management.

Frances Martini, R.N.

What kinds of elements make it challenging to connect with them around their care?

You can’t look at all 600,000 people at once; it would be totally overwhelming. So we look at sub-populations. We look at age-based cohorts, including 0-4 years of age, and 5-20. And clearly, a four-year-old is very different from a 15-year-old. And clearly also, different things affect newborns from those that affect 55-year-olds. So we divided our population into sub-populations—small children, school age, young adults, and so on. And you know that a 0-4 doesn’t have behavioral or chemical dependency, but they could have disability, etc. And with school-age kids, behavioral or chemical dependency might be high, but cancer won’t be. So we looked at those elements. And for the 5-20 population, behavioral and chemical dependency is number one in terms of risks, and asthma is second. Behavioral is around 15 percent and asthma is 10 percent, and of course, you can have both. Obesity is also very significant; and so are developmental disabilities. So for me, in putting my team together, I have to be familiar with those conditions, know I have a network that can handle it, where those members are, and have a staff to manage them. Because the kind of staff that would manage newborns would be very different from a staff that could manage school-age kids.

And I have to look at what’s happening in the community; and what’s going on in the schools; things like what the school nurses are doing; the contact level with the parents; the educational levels of the schoolchildren. And that’s where the data is so important.

In your presentation that was part of the Medicaid & Health Policy Summit track and the Behavioral Health Summit track, you talked extensively about the value of data, to population health management and care management work of the type that you and your colleagues are engaged in.

Yes, in fact, I actually participated in two panels at the World Health Care Congress; I did a second panel around informatics. And the thing is that, without the data and being able to have someone help you interpret the data and make sure you’re tracking it correctly, it’s useless. So he and I did a presentation together, and he did one of those ‘be careful what you ask for’ kinds of things. Because sometimes clinical people don’t want they’re asking for. We actually call people like him “data clinicians.” He helps us think through what’s happening and what we’re doing, and how to track it. So we might start out saying, for example, we want to set up an asthma program. But what we found out was that the asthma problems we had are with children from zero to four. Clinicians will tell you that most children that age don’t have asthma diagnoses. But we had so many children in the ED with asthma symptoms, that we ended up creating a program to help manage that. So that’s the beauty of informatics, not only helping us to identify a population, but also how to manage that population, and how to intervene.

So once you’ve identified a subgroup, then what are the next steps that you take?

Yes, for example, we had a very small subset of our population—less than 1 percent—with very high medical costs, and who were frequently admitted, but who still weren’t getting better. Our data showed us that they were utilizing services, particularly hospital services, but they weren’t going to the doctor. They weren’t utilizing primary care.

Were they usually just going to EDs with symptoms?

Yes, and often being admitted. So we said, how are we going to address this? So we did was that we decided to look at people with 10 or more admissions a year. We came up with 285 people who were really, really at the top, and we said, wow, that’s not very many. So we have something called Persona. We have not only internal data—our stratification tools and so forth; we actually purchase data from external sources, like Experian. So I looked at a 65-year-old woman with diabetes—she lives in an area with families, and she’s not homeless. That, compared to a 65-year-old woman with a similar diagnosis, but who’s using the ER all the time, but I can’t address her situation the same way. So we did a deep dive, and found that in both cases, we had tried to reach out to them. But we could never find them, could never get to them. So we identified where they lived, and the staff just found them. One of them was in dialysis, so we said, wow, we know where she is, let’s just go there. The other one, we flagged her record, and went to the hospital when she was admitted. And the lady who was in the family area just didn’t want to be a burden. So we talked her and said, don’t you want to be around when your grandson gets married? That kind of thing. The lady who was in dialysis and who was homeless, we worked with her to get housing and disability and things like that. Her life isn’t perfect, but we did what we could. And we helped.

So part of it really was almost like working as private investigators, tracking them down, right?

Yes, I hate to say it, but yes, that’s what it was like. And sometimes, a staff member could figure out where the member was. And sometimes we knew where they were in terms of apartment buildings, etc. We did a lot of what we call “drive-bys,” even though that’s not an ideal term. But we did find every single one of those 285 people; it took about two to three months to do so. But we got to the point where we knew where they were. To give you a couple of examples, one time, someone said, oh, that member was just admitted! And we said, go run over there now! In another case, one of our staff knew the sister of a plan member. He lived with a bunch of other folks in a group home, and we were able to find him.

And once you do track down those members, how do you get member engagement with them?

We call it meeting them where they are. We meet with them and find out what they want. My goal might be, let’s not have you in the ER all the time. Their goal might be, I need food, or to be with my family. And the only way to get results is to help them get what they want. The Case Management Society calls it integrated population health or integrated case management. We don’t start out with, “Have you ever had asthma,” or whatever; we start with, “How are you?” And they might say, “My son is living with me, and I can’t get him out of the house.” So we don’t immediately say, “Have you had a pap smear?” And she might seek ER care because of her living situation. So we have to figure out that situation. And we could say, ‘Why don’t you move?’ But that’s not what she wants. So we have to work out her situation for her. And sometimes it means we have to fix what’s wrong with the family or the situation…

There’s this myth that keeps perpetuating itself that people on Medicaid don’t care about their health, but that’s not true. Could you speak to that myth?

You’re exactly right, it’s a myth. Sometimes, their choice is between buying food or fulfilling their prescription. Here’s an example: the electricity was turned off on a family, and their child had a tracheotomy, and without electricity, they couldn’t suction their child. So I called the electric company, because it was an emergency. And they said, “No, I can’t pay it because I need an account number.” So we went out on a well-check visit with the police. And it turns out, the mother didn’t have enough money to pay the electric or the phone bill—and the other children were suffering, too. So they were able to locate the mother’s father, and the police took the mom and baby over to the grandfather, where there was electricity. And we got her a free cell phone that she was eligible for, because of Medicaid, and got her a grant for the electricity. So then we could focus on the kids getting their immunizations and making sure the baby was able to be suctioned.

And sometimes, the amount of money involved is actually tiny compared to people constantly rotating through the ED or hospital, right?

Yes, that’s exactly right. You think about a $700 ED visit versus a $200 electric bill, which would you rather pay? The struggle is getting them to the PCP. And sometimes, the behavioral problem comes out of needs, like hunger. So we do things like making sure the nurses have snacks, like Lunchables, so that they can better cooperate with the doctor. You know, there’s a quote that talks about population health, especially in dealing with Medicaid. And the quote is about the broken families, the lack of money, the lack of access to any kinds of services. It’s not about solving a purely medical problem, it’s about solving all the problems. It was the population health group at Jefferson Hospital. I use it in almost every presentation, to get people used to what you have to deal with, even with our staff. The quote comes from David B. Nash, M.D., dean of the Jefferson School of Population Health, at Thomas Jefferson University in Philadelphia. He says that, to improve population health “It’s the housing, it’s the lack of access to food, it’s the broken families, it’s all that messy stuff. It’s a complex story, so it can’t have a medical fix to make it work.”

What should CIOs and CMIOs be thinking about, as they consider the advances that you and your colleagues have made, in this initiative?

I would tell them that, first of all, numbers have an important story to tell, and they need to rely on those numbers. Our informatics team is part of our clinical team. We talk about “data journalists,” those who tell stories with their data. I would say their informatics and clinical folks need to be in with their data analysts from the beginning. It’s kind of like what a CIO does, they translate the systems for the users. They’re like that piece in the middle, to make sure the people in the business get what they need.

And often, it’s the clinical informaticists in hospitals and health systems, who bridge the IT and data people and the clinicians, in efforts like this one.

True, but in any case, the more closely they all work together, the more likely it is that you’ll come up with a good approach. And we’re huge on control charts—I was at an IHI workshop on the use of control charts, where you have a mean, and you know what your standard deviation is, and you know when you’re tracking an activity and you’ve got so many data points above the mean, you know you’ve got a significant variance. And when you create a plan, and then you have a process change and you track it, and see positive change as a trend, you know that you’ve made a difference. And if you do something and you don’t see change, you need to stop it and do something else. So you can say, OK, I tried this and it didn’t work, but the variance that occurred wasn’t based on that. And I’m a nurse, and it’s helped me in my career to not waste time and money. And I always look at the example of Florence Nightingale, who tracked deaths on the battlefield, and was able to identify infections and improve sanitation.

Do you have any metrics that you can share, with regard to some of the results you’ve achieved?

We’ve had four major interventions, and have been able to show improvement in inpatient admissions. And we’ve been able to translate that into a savings of over $650,000. We found that, among those 285 people—we ended up with about 250 people as we went through the year, because a few were disenrolled or died—but we saw a statistically significant reduction in admissions, and we saw a reduction in costs, without any additional outlay of expenditures or staff. That’s the beauty of data.

What will happen in the next couple of years, as this initiative evolves forward?

We’ve expanded this approach to the next level, and we’re working to see what lessons we’ve learned—finding Medicaid members is a challenge, but we’ve been using some of the same approaches with the less-acute. And with a lot of the technology out there—a lot of patients and members will self-manage, but you also have to work with the populations you have, and work with the tools you have. It will be interesting to see what happens with healthcare, and with Medicaid expansion or not. We have 6 million people in Tennessee, and 20 percent are on Medicaid. That’s a huge percentage of people who depend on us. And we’re going to have to use data in a good way.

And you’re all about working with providers, correctly?

Absolutely, absolutely! And you know what? Doctors love data. And it’s OK for me to stand up and talk about 600,000 members, but the individual physicians want to know about their 1,000 members each. And we’re paying physicians more the better members get. So that’s where things have been headed.

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Successful OpenNotes Implementations Require Portal Changes, More Communication

December 14, 2018
by David Raths, Contributing Editor
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Some health systems report low note-opening rates; others haven’t measured
The OpenNotes movement, in which healthcare organizations offer patients access to their clinical notes in the portal, has spread like wildfire. In just a few years it has grown to 184 confirmed health systems, with another 31 that have implemented but not documented their use, and more expressing interest every day. Yet at many healthcare organizations, the percentage of portal users reading clinical notes is still quite low, according to a new white paper and recent webinar by the nonprofit OpenNotes team.
When OpenNotes asked clinical groups for data on note-opening rates, most said it was something they did not measure, and indeed most EHR portal designs do not make it easy for them to gather that data. The OpenNotes team did collect data from 26 organizations and found that four organizations, two with homegrown EHR systems and two on Epic, had the best open rates — ranging from 21 to 34 percent, followed by eight organizations with 6 to 10 percent, with the bottom 14 reporting only 0.27 to 5 percent open rates. 
“We were stunned by the results,” said John Santa, M.D., M.P.H., OpenNotes’ director of dissemination. In many organizations, turning on OpenNotes was described as a non-event. “Sad to say that is because in some cases not much is happening,” added Santa, who played a leadership role in starting the Northwest OpenNotes Consortium and he now leads the development of future consortia. One problem is that in some cases patients are not aware of their notes or can’t find them. “Now we do know of many robust implementations where tens of thousands of patients are seeing their notes and are feeling the benefits,” Santa stressed. “But for OpenNotes to lead to best outcomes, we need to take steps to maximize the benefits.”
Their white paper notes that from the data they have gathered, “it is likely multiple factors, including portal navigation, lack of or ineffective reminders to read notes, and insufficient communication strategies contribute to low note-opening rates.”
“What we have learned is that turning it on is not sufficient,” said Cait DesRoches, DrPh, OpenNotes’ executive director and associate professor of medicine at Harvard Medical School. “Evidence suggests patients are not aware that they can read notes or they can’t find them.” Additionally, clinician anxiety around transparency is still an obstacle, she said. 
Santa noted discrepancies among customers of different EHR vendors. He said that while there are many Cerner, Allscripts and Meditech customers deploying OpenNotes, they have not developed ways to generate note-opening rates for customers. Epic, he said, has launched multiple near- and long-term changes to improve note-opening rates and included note-opening metrics in recent versions of its dashboard.
During the webinar Marcia Sparling, M.D., a rheumatologist and medical director for informatics and specialties at the Vancouver Clinic in Vancouver, Wash., made some observations about her organization’s experience. The Vancouver Clinic started piloting OpenNotes in 2014. It has a high patient portal usage rate of 82 percent, and early note-opening rates were close to 20 percent. But when the clinic did an Epic upgrade with a redesign of MyChart, the rate fell to 11 percent. “We looked at how we could help patients find the notes and why they might be missing the prompts,” Sparling said. They made a few changes. First, after-visit summaries generate an e-mail urging patients to log in, a hyperlink directs them to their past appointments page, and once there, they see wording that says “Click on your clinical notes.”
“We re-labeled that tab to ‘clinical notes’ to be more obvious,” she said. The current rate or note opening sits between 22 and 24 percent, she added, noting that there are some wide variations between specialties, although there is no obvious explanation for the disparities.
The OpenNotes white paper spells out the steps the Vancouver Clinic took to improve their note-opening rates: 
• Quick Link within MyChart patient portal (labeled ‘View clinical notes shared by your provider’); 
• Text at top of Visit Summary section directs patients to click on Clinical Notes tab; 
• MyChart home page ‘News for You’ contains paragraph on notes and a hyperlink; 
• Notes are viewable on both the Visit Summary report and the Clinical Notes tab (with some exceptions); 
• Clinicians’ notes are shared by default (with a few exceptions); 
• Auto MyChart message sent to portal user when visit is closed: Message subject reads ‘New MyChart@TVC Visit Note’; the body of message contains navigation steps and hyperlink directing patients to Appointment and Visits page.
OpenNotes is in the early stages of working with clinicians, patient groups and EHR vendors to develop metrics around use of the portal and note-opening rates. It says the definition used by Epic is reasonable as a starting point (this definition applies to notes shared over any defined time frame): Numerator = Notes listed in denominator that are viewed by a patient portal user. Denominator = Signed notes from completed encounters written on a portal active patient (or patients activated within a month of the visit) that are shared to patient portal.

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Who Isn’t Using Patient Portals? New Study Sheds Light on Portal Use

December 12, 2018
by Heather Landi, Associate Editor
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About two-thirds of adult patients did not use an online patient portal in 2017, and research indicates vulnerable and disadvantaged patients are less likely to use these technology tools, according to a study published in the November issue of Health Affairs.

Technologies such as online patient portals, which provide secure internet access to medical records and test results in addition to email communication with providers, can improve health care quality. And, evidence thus far shows that access to online portals increases patients’ engagement and adherence and may reduce unnecessary utilization and spending.

However, while the majority of adults in the United States believe that online access to personal health information is important, disparities in portal access exist.

“Findings from multiple studies that analyzed different population groups, including nationally representative samples, consistently show that members of racial and ethnic minority groups, older patients, and people of lower socioeconomic status are less likely than others to access an online portal,” the study authors wrote. The study was led by Denise Anthony, professor of health management and policy and sociology in the Department of Health Management and Policy, University of Michigan School of Public Health. Anthony and her co-authors also note that “inequities in access to new and beneficial technologies can exacerbate existing disparities in health.”

One national study, a March 2017 by the U.S. Government Accountability Office (GAO), found that only about 15 to 30 percent of patients who were offered access to a portal used it, with lower use among people living in rural and high-poverty areas.

“To identify appropriate levers that can be used to address inequities in online portal access, policy makers and providers must have a clear understanding of who is and is not accessing portals, as well as the reasons for not accessing them,” the study authors said.

For the study, titled “Who Isn’t Using Patient Portals and Why? Evidence and Implications from a National Sample of U.S. Adults,” researchers analyzed information about 2,325 insured respondents to the nationally representative 2017 Health Information National Trends survey to examine characteristics of patients who do not use portals and the reasons why they don’t them. By identifying who is not using portals and why, the researchers sought to uncover barriers and reduce disparities.

The study indicates that about two-thirds (63 percent) of insured adults with a health care visit in the previous 12 months reported not using an online patient portal. The research indicates that nonusers are more likely to be male and age 65 or older, have less than a college degree, not be employed, live in a rural location, be on Medicaid, and not have a regular provider.

These factors, along with race, were also related to whether a patient reported receiving an offer to use a portal.

Relative to females, males had significantly higher odds of not being offered access to and not using a portal, the study indicates. Members of racial minority groups (specifically, non-Hispanic blacks and non-Hispanics of other races—including Asian Americans, Native Americans, Native Hawaiians, and Pacific Islanders) had significantly greater odds of not being offered a portal. Among only those who were offered a portal, these groups reported rates of using a portal comparable to the rate of non-Hispanic whites.

The study also found that people with only a high school diploma or less were significantly less likely than those with college degrees to have been offered access to a portal. Patients with Medicaid insurance were significantly more likely to report not having been offered access to a portal and not using one, compared to people with other insurance.

Patients who lacked a regular provider were significantly more likely to report not having been offered access and not using a portal.

When evaluating reasons why people did not use a portal, the researchers did not find evidence of disparities in technological barriers. The reasons patients gave for not using portals included the desire to speak directly to providers and privacy concerns, both of which require recognition of the important role of provider communication and patient-provider relationships, the study authors note.

The study authors conclude that healthcare providers will need to address patients’ privacy and security concerns to enhance provider-patient communication.

“Reducing disparities in portal use will require that providers, particularly those serving vulnerable populations, communicate with all patients about portal use and have the capacity to discuss these technologies with patients,” the study authors wrote.

“Health care providers and plans can increase patients’ use of portals and narrow disparities in that use through direct communication about the benefits of portals, while also addressing patient-specific needs and concerns. Such interventions will require recognition that providers’ communication with patients takes time—an extremely scarce resource in clinical practice today,” the study authors concluded, while also noting that careful monitoring of who is and who is not using new technologies, and why, and designing technologies to address patients’ needs, will help ensure that such innovations do not exacerbate disparities but rather lead to improvements for all.

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AMIA, AHIMA Call for HIPAA Modernization to Support Patient Access

December 7, 2018
by Heather Landi, Associate Editor
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Modernization of the 22-year-old Health Insurance Portability and Accountability Act (HIPAA) would improve patients’ access to their health information and protect their health data in a burgeoning app ecosystem, according to two leading health IT industry groups.

During a briefing on Capitol Hill Wednesday, leaders with the American Medical Informatics Association (AMIA) and the American Health Information Management Association (AHIMA), health informatics and health information management experts discussing how federal policies are impacting patients’ ability to access and leverage their health data.

While other industries have advanced forward with digital technology and have improved individual’s access to information, and the ability to integrate and use information, such as booking travel and finding information about prices and products, healthcare has lagged. Healthcare has not been able to create a comparable patient-centric system, AMIA and AHIMA leaders attested.

“Congress has long prioritized patients’ right to access their data as a key lever to improve care, enable research, and empower patients to live healthy lifestyles,” AMIA president and CEO Douglas B. Fridsma, M.D., Ph.D., said in a statement. “But enacting these policies into regulations and translating these regulations to practice has proven more difficult than Congress imagined.”

“AHIMA’s members are most aware of patient challenges in accessing their data as they operationalize the process for access across the healthcare landscape,” AHIMA CEO Wylecia Wiggs Harris, Ph.D. said. “The language in HIPAA complicates these efforts in an electronic world.”

AMIA and AHIMA recommend that policymakers modernize HIPAA by either establishing a new term, “Health Data Set,” which includes all clinical, biomedical, and claims data maintained by a Covered Entity or Business Associate, or by revising the existing HIPAA “Designated Record Set” definition and require Certified Health IT to provide the amended DRS to patients electronically in a way that enables them to use and reuse their data.

According to AMIA and AHIMA, a new definition for “Health Data Set” would support individual HIPAA right of access and guide the future development of ONC’s Certification Program so individuals could view, download, or transmit to a third party this information electronically and access this information via application programming interface. Alternatively, a revision of the current DRS definition would provide greater clarity and predictability for providers and patients.

The groups also noted that a growing number of mHealth and health social media applications that generate, store, and use health data require attention as part of a broader conversation regarding consumer data privacy.

Congress should “extend the HIPAA individual right of access and amendment to non-HIPAA Covered Entities that manage individual health data, such as mHealth and health social media applications, the two groups said. The goal is uniformity of data access policy, regardless of covered entity, business associate, or other commercial status, the group leaders said.

Beyond HIPAA, during the briefing Wednesday, panelists discussed the success of efforts to share clinical notes with patients during visits, including the successful OpenNotes initiative, and recommended that federal officials look for ways to encourage more providers to share notes with patients through federal policies, such as Medicare and Medicaid payment programs.

“More than two decades after Congress declared access a right guaranteed by law, patients continue to face barriers,” Thomas Payne, M.D., Medical Director, IT Services, UW Medicine, said in a statement. “We need a focused look at both the technical as well as social barriers.”

What’s more, AMIA and AHIMA recommended federal regulators clarify existing regulatory guidance related to third-party legal requests, such as those by attorneys that seek information without appropriate patient-direction.

“HIM professionals continue to struggle with the existing Office for Civil Rights guidance that enables third-party attorneys to request a patient’s PHI,” Harris stated. “We recognize there are necessary circumstances in which a patient has the right and need to direct their health information to an attorney. However, AHIMA members increasingly face instances in which an attorney forwards a request for PHI on behalf of the patient but lacks the information required to validate the identity of the patient. As a result, the HIM professional is challenged as to whether to treat it as an authorization or patient access request, which has HIPAA enforcement implications

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