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Blue Cross Blue Shield Nebraska Leverages Mobile Tech to Improve Plan Member Engagement

March 27, 2018
by Mark Hagland
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Blue Cross Blue Shield Nebraska moves forward to engage plan members in their care management

The Omaha-based Blue Cross Blue Shield Nebraska serves 500,000 lives across the Cornhusker State. With strong relationships with providers across the state, BCBSN’s leaders continue to try to advance their progress in care management, population health management, and plan member engagement.

In that context, BCBSN’s leaders have been working in improving their care management operations, through enhancing the touchpoints of their plan members, as they transition to post-surgical care, and across their ongoing chronic condition care management. In that regard, they’ve tasked their care managers to more fully engage with plan members, making using of a mobile-based solution to amplify care management so that it’s an ongoing touchpoint for patients in the longer term — with some excellent results. For example, BSBCN plan members have been able to meet 96-percent medication adherence, post-surgery, while case managers are now spending less than half the time it took previously to reach health plan members (from eight minutes down to 3.5 minutes), using that mobile solution.

The leaders at BCBSN have been partnering with the Boston-based Wellframe, which offers mobile patient engagement and care management software. Wellframe’s care programs turn health management into an interactive, personalized, and educational daily to-do list delivered to patients’ mobile devices.

Susan Beaton, R.N., vice president of provider services and care management, at BCBSN, spoke recently with Healthcare Informatics Editor-in-Chief, Mark Hagland, regarding the insurer’s leveraging of mobile technology to support its care management and wellness efforts. Below are excerpts from that interview.

Can you tell me a bit about BCBSN’s overall population health management and care management strategy, and how this mobile-leveraged care management initiative fits into that overall strategy?

About four years ago, we decided to look at our traditional care management programs, which were based on reaching out to members who needed our assistance, but it was done by invitation through the email, through a physician, referral pattern; but we knew times were changing, and that our members needed real-time interaction, and meeting them where they needed us to be. And at that time, we didn’t have a mobile platform, and knowing that we needed to make that switch, knowing that health happens at home and at work, and we knew we needed to meet members where they were, and that’s usually away from their home phone. That’s when Jake [Jacob Sattlemair, CEO of Wellframe] and Joann Schaefer, M.D., our executive vice president—who was at that time our CMO—first touched base.

Susan Beaton, R.N.

And it went fast. Once we started to meet, we realized that Wellframe was really something special. They were able to take a look at what we were doing, and identify what their tool was able to do for us and our members. And in 2015, we were up and running on a pilot program for our nurses and members. Their goals were very similar to ours; we’re very agile and innovative. It became a great collaboration.

What was the core focus of the initial pilot?

We looked at our program that helps our members when they discharge from the hospital and go back home, and looked at how we could interact with them by phone. At that time, that was one of our greatest needs, and that’s where we started. So it launched, and it was successful. We were looking at the interactions our nurses were having with our members: it was real-time, it was relevant.

It was care management-type counseling over the phone?

It was both educating them about their medical condition, and  answering benefits questions over the phone. Their medical condition, their pharmaceutical needs, and their benefits. Initially, it was about 1,000 members a month discharged from the hospital, with seven nurses. And it really went very fast, and has expanded ever since. We’ve ended up putting every single one of our care management offerings onto the Wellframe platform.

We have Transitions of Care, Health Coaching, Chronic Disease, Catastrophic Case Management, Maternity Management, Presurgical and Postsurgical Care Management; and Emergency Management will be next. We found we needed to offer everything via both our traditional mode and the Wellframe platform. So it’s been continuous development ever since.

Have you encountered any challenges in developing this?

Well, sure, with any program, you always have challenges, but we were able to address those with Wellframe, and Dr. Schaefer, and our nurses, etc.

Have you used this solution to work on readmissions reduction at all?

We started with a basic measure in terms of interventions. Over half of our members no longer have home phones. So if we were using traditional measures and tried to reach a home phone or send them a letter in the mail, we found that we were often not connecting. Using this mobile solution, we found that our engagement rates immediately went up. Before, we were lucky to get maybe one or two communications every couple of weeks. Using the dashboard, though, they would chat in real time. And nurses were able to get alerts from Wellframe in real time, letting them know what communications had taken place. It was through an app or via the website, that they were reaching out.

We started out simply; for most plan members/patients, the most confusing thing is remembering what their discharge instructions were, so Wellframe was able to build into the platform to help the member understand the discharge instructions. Did they have any questions? We knew that members… Let’s say somebody went home from the hospital after surgery. If they needed follow-up care or medication adherence education, we were able to send them information—so, four pieces of content of information. What was fantastic was we were able to verify that they had consumed the content, and if they had questions. That was a fantastic advance for us. We were able to get instantaneous feedback. And a couple of times a week, we would find out how they were doing with their follow-up routine, and if they had questions, etc. Through the continuous questionnaire format, or even via live chat, we were able to get feedback from them. We know members are busy, too, and we were able to get them information conveniently, and we knew members were responding to us. We wouldn’t have gotten that via traditional means, so that was a fantastic learning.

Another incredibly important element is following up with a primary care physician visit after discharge; and 77 percent of the time, we had confirmation that they had seen their PCP. Either we would ask them directly, or we would check claims or visit appointments.

Are you going to expand this in some way?


The next step that we just rolled out in February—when we try something that turns out to be successful, we know it’s important to support our physicians. And knowing that members also reach out to their physicians, we knew we needed to incorporate this tool into our communications with physicians. So in February, we were able to incorporate this into our work with one of our ACOs, in terms of communications with physicians.

So this has been rolled out to physicians so they can communicate with you?

It’s live now, in that particular ACO.

How many physician practices is it live in?

It’s being launched through a care management organization that’s working with that ACO. It’s one large physician clinic that is involved.

What have the biggest learnings been so far, in terms of engagement with patients/members and physicians?

One of the learnings has been what we’ve learned internally. Members very easily explained what they needed to be successful. They love the new technologies, and love interacting with the nurses. They still get compassionate nursing, but it’s real-time, and it enhances interactions. We have to interact with members wherever they are—at home, at work, on the go. We really needed a tool to achieve that, as we continue to do everything we do already that enhances our patients’ health. And once we got those up and running, it was so quick; and getting the next piece in, and when our nurses can see the difference they can make.

When we can get a 400-percent increase in touchpoints, that just energizes the nurse case managers more. We inspected the information, took in the feedback, and made the changes. It’s been a fantastic experience. So, our nurses and members first, then, how we interact with physicians. And then, what will happen with members who just have benefits questions? So each year has brought new innovation and change. We have to be able to change like that for our members.

Is there anything you’d like to add?

Wellframe was able to take away some of the pain points we had had around not being able to reach our members—for example, if they were traveling away from home, they weren’t getting letters. So Wellframe has been able to alleviate those obstacles. And we were able to reach more members, have more meaningful engagements, increase their capacity; and it drives cost savings; and helps our members understand their benefits; and where to get highest-quality, low-cost care, and how to use the system. Those have been the biggest learnings. This is what our members want.





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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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