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Cedars-Sinai Medical Center Deploys Text Messaging Platform To Enhance Patient Communication, Engagement

August 19, 2016
by Heather Landi
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Los Angeles-based Cedars-Sinai Medical Center has tapped a digital health startup that came through its inaugural healthcare accelerator program to deploy a digital tool that enhances patient communication and engagement.

The health system has partnered with West Hollywood, Calif.-based startup Well on a secure text messaging platform that will enable front office staff to more effectively communicate with patients.

Cedars-Sinai, a 900-bed hospital and multi-specialty academic medical center with 2,100 physicians, will soon be installing Well’s communication technology across multiple departments, allowing front office staff to interact with patients via text message as well as offering a secure way to gather and store highly-sensitive patient data into the organization’s electronic medical record (EMR), according to a press release.

Well’s HIPAA compliant, enterprise-grade communication software will be installed on staff computers, and immediately adds text messaging capabilities to the health systems’ phone numbers. Incoming messages are routed to the appropriate staff member, and surface pertinent patient information from the medical record to accelerate triage and resolution.

Gene Liu, M.D., otolaryngologist, head and neck surgeon at Cedars-Sinai, says communicating with front-office staff can be a frustrating, time-consuming process for patients. “If you’ve ever called a doctor’s office, you either get an automated phone message or you’re put on hold. It’s always an adventure. Being in healthcare, I go through the back end and text message doctors and staff directly.”

Gene Liu, M.D.

Liu adds, “If that’s the service I want and expect, then, in the end, it’s just so much easier when patients can text the office.” Liu says he sought out the Well team when he learned about their participation last year in the inaugural Cedars-Sinai TechStars Healthcare Accelerator program.

“We’ve since deployed Well’s technology and it has completely transformed the way we engage patients. Our staff is more effective, more efficient, and patients love it,” he says.

Joe Tischler, co-founder and COO of Well Health, says within the healthcare setting, the way front-office staff communicate with patients has not been keeping pace with the communication mediums that people use in everyday life.

“In healthcare, you have all this technology, but at the end of the day, a lot of it benefits the clinician and the technology that staff are using on the front end really hasn’t changed for 20 or 30 years. It’s about time to keep up with how people actually communicate in their daily lives, so that’s the vision of why we did Well.”

Cedars-Sinai also will bolster its patient service by deploying bots that proactively inform and respond to patients regarding appointment time, location, directives, paperwork and more. These automated messages are an extension to the real-time, manual monitoring and response by front-office staff.

“I want to say a large portion of phone calls to the office are for simple information exchanges or questions about appointments or what’s the address, and those are all things that can be done via text message. So from the perspective of patients getting in touch with the office and getting answers to questions, it’s just better through text message and patients feel more connected and engaged,” Liu says.

The text messaging capabilities also enable front-office staff to more quickly and effectively communicate with patients, he says.

“There are many times when, as one example, I have an emergency and you need to call the patients to say, “sorry, something came up, can we move your appointment?” So the front-office staff are calling people, but they’re not answering. And then we said, why don’t we just text them. And half of them were at work and in meetings, so they couldn’t answer the phone, but they were texting back," Liu says.

Shayla Brewer, patient service representative for the adult and pediatric ear, nose and throat clinic at Cedars-Sinai Medical Center, says, “Patients are responding quicker to things we need an immediate response to and are more involved with us here at the office through this communication pathway. It’s connecting us and keeping patients engaged and keeping them happier and really improving the experience overall with the department.”

Liu adds, “It makes the communication more streamlined and straight forward. We even have separate text lines for surgery schedulers, so there a lot of easy ways to direct traffic.”

Tischler and co-founder Guillaume de Zwirek, CEO of Well and a former project manager at Google, developed the text messaging communications software platform based on Tischler’s experience in healthcare technology and their individual experiences as patients.

“We’ve had a lot of frustrations as patients trying to understand why it’s so hard to get a hold of anyone, and why everything had to be done on the phone and we noticed all the synergies that were missing in terms of communication,” Tischler says.

While text messaging within healthcare settings for internal communications is fairly common, Cedars-Sinai’s deployment of the messaging communications platform to specifically communicate with patients is pioneering, according to Tischler. Last year, the Federal Communication Commission moved to amend the Telephone Consumer Protection Act for healthcare and created an exemption applying to robocalls and texts to wireless numbers for things like appointments and exams, confirmations and reminders, hospital pre-registration instructions and pre-operative instructions and post discharge follow-up.

“Messaging in healthcare is not necessarily new, but a lot of options out there have been mostly for internal messaging within an institution, so pager replacement,” Tischler says. “When we started working on this, there was no one out there doing it. So, it’s the right place, right time. And, I think we’re also at a critical mass where, generationally speaking, you have actually have patients from young to geriatric who are using text messages. Some people might not know how to initiate text messages but they all know how to respond to them.”

Over time, Cedars-Sinai plans to provide the ability to complete paperwork, check eligibility, bill pay and complete other administrative tasks over text message.

Text messaging also could serve as an efficient way to communicate pre- and post-procedure instructions to patients and to better engage patients about managing their conditions, Liu says.

“If we’re relaying some instructions to patients, such as whether or not they should be taking a medication, or instructions such as, 'here are five things that I want you to do over the next week,' if it’s there in the text message, they can reference it easily. If you have an easy way to relay information on their phone and patients can reference it at any time, that is going to improve compliance. If somebody is coming in for a procedure, and you can send them reminders of what not to do, or medications to stop before the procedure, a lot of things like that that can, either directly or indirectly, improve outcomes,” Liu says.

And, beyond just basic communication, many clinicians and physicians see text messaging as a better way to connect and engage with patients.

Tischler says, “One of the biggest vision points we had with Well was to make messaging as commonplace as having a phone in the front office. Most patients love their doctors, but hate going to the doctor’s office. So, we can change the conversation and add meaningful touch points between patients and office staff.”

Liu adds, “There is a link between engagement, satisfaction and quality, so, in a very simplistic way, the happier patients are, the more likely they are to listen to you.”





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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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