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How BayCare Health System is Using HIT to Meet Patients Where They Are

May 8, 2018
by Heather Landi
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BayCare Health System, a 15-hospital system based in Clearwater, Fla., is moving forward on many technology fronts to enhance patient engagement and patients’ access to their medical records, as well as expand healthcare services through digital platforms.

BayCare Health System is one of 39 health systems across the country collaborating with tech giant Apple on its health records initiative. The Health Records feature is now available through the health system for patients who have downloaded iOS 11.3 to their phones. Apple announced its health records solution in January with 12 health systems participating as beta testers, and two months later, on March 29, Apple tripled the number of health systems participating, from 12 to 39, which increases the number of patients across the country who can view their medical records right from their iPhones.

A recent report from Orem, Utah-based KLAS Research found that CIOs at the 12 early adopter health systems were optimistic about the Apple Health Records app, and the short-term and long-term potential to impact how provider organizations interact with patients and how patients manage their health. Close to 60 percent of respondents said they expect Apple’s “ready-to-go” patient-record portability to have an immediate positive impact, within zero to six months. According to the report, healthcare executives mentioned three primary benefits of the app—empowering patients, helping to solve interoperability, and speeding innovation and change.

BayCare Health System has made patient information available through the myBayCare patient portal online for several years. The patient portal also is accessible through the BayCare app. Tim Thompson, senior vice president and CIO at BayCare Health System, views the Apple Health Records initiative as another step to improve patient engagement and enhance patients’ involvement in their own care.

“It’s just another avenue for a health system’s patients to have their information at their fingertips. It’s still based off the exact same data that comes out of our portal, so if somebody is used to Apple technology and does other tasks in the Apple health app, that’s another piece of their personal health information that they have at their fingertips inside their app. That is now live and available to patients,” he says.

Tim Thompson

Since Apple’s health records announcement, industry observers have questioned if the tech giant would be able to succeed in creating a health records platform, especially since other consumer-oriented healthcare outsiders, specifically Microsoft and Google, have failed at this very endeavor. According to the recent KLAS report, Apple’s early provider partners believe Apple has a good chance of not repeating history and that the timing is right. “EMR adoption has never been higher, and thus electronic records have never been as available; smartphones are more entrenched than ever; and interoperability standards (like FHIR) have never been as advanced,” the report stated.

“I think largely those [previous] efforts reflect hospitals putting as much information online as they could to meet a meaningful use criteria, and it wasn’t that helpful to patients,” Thompson says. “Once you get home from the hospital, at least for me personally, I’m not that interested in looking at what my lab values looked like five days ago in a hospital. However, if I’m a chronic patient, and now it’s in my ambulatory office, in my doctor’s office, in my clinic, or at my urgent care center, now I can go in and get my blood tests, on a routine basis, and now I can look at that information and I can see trends. That gives the power to the patient to help them manage their health. I think that’s the difference. I think early on, it was about an encounter at a hospital, and now it’s about managing your health.”

He adds, “At BayCare, for example, whether you have been at our hospital, our urgent care center, at one of our physician’s offices, or to our lab, all those pieces of information are there for the patient to access, and patients can be a part of managing their own care better.”

The KLAS report on the Apple Health Records initiative found that, among the early adopters, most organizations’ formal plans for it are limited to its most immediate benefit—allowing patients to download their patient records. “This benefit requires relatively little time, effort, or cost from healthcare providers,” the KLAS report stated.

Thompson echoes this perception that integrating with the Apple Health Records app requires very little lift for providers. “The fact that [the IT team] completed the integration in two weeks indicates that it went incredibly smooth. Both Cerner and Apple were engaged with our team and we were able to get that done very quickly,” he says. Currently, Apple’s electronic health record (EHR) vendor partners are Epic, Cerner and athenahealth.

Beyond the Apple health records initiative, BayCare Health System is keenly focused on a patient engagement strategy that “meets patients where they are” by offering information and services through a mobile technology platform. “I think that consumers, in general, including potential patients, are used to interacting with their information in a mobile way, whether it’s their bank, airline or hotel; that’s the mode they are used to dealing with their information,” Thompson says.

He continues, “For those people who really engage in the Apple app, it’s just enabling them to have BayCare as an option in that. We serve a population, particularly in a couple of our counties, that often spend six months here during the winter, and then six months up north somewhere, and this feature gives them access to their medical information at their fingertips. And, if their health system up north does the same thing, then it gives them a full picture of their health as they move north and south.”

BayCare Health Systems’ patient engagement strategy encompasses the patient experience as well, and last fall the health system launched a free mobile wayfinding app, BayCare Compass, to help patients and visitors locate their destination at a hospital. The health system plans to have the app in use at all 15 BayCare hospitals by 2019.

"More and more, BayCare is utilizing apps and technology to deliver services and streamline access for patients and their families. BayCare Compass is another way that we can provide patients and visitors what they need and want—information in the palm of their hand that makes using the hospital easier,” Thompson says.

BayCare has deployed a number of technology-based solutions to enhance care and improve access, including HealthNav, a mobile app to help guide people with non-urgent conditions to medical services; telemonitoring of patients in nursing homes or rehabilitation facilities; eCare, an electronic patient monitoring system to monitor critically ill patients in the hospital intensive care unit (ICU) and BayCare Anywhere, the system’s telemedicine service.

“We have also been pretty focused on telehealth and televisits for a few years now, and not necessarily just for the routine visit; we monitor all of our ICUs remotely, and we do some wound care management with telemedicine as well,” he says.

In January, BayCare Health System announced a collaboration with the grocery store chain Publix to launch Walk-in Care Provided by BayCare. These in-store telehealth centers will be available at 26 Publix Pharmacy locations by the end of the year. The telehealth centers feature an interactive kiosk enabling patients to enter their symptoms and work with medical tools such as thermometers, otoscopes, blood pressure cuffs and high definition cameras to help doctors, available through teleconferencing, to make an accurate diagnosis.

Thompson and his team are also increasingly focused on leveraging the health systems’ enterprise data warehouse (EDW) to advance business intelligence initiatives. “Our focus on that is ensuring that we have accurate data in the warehouse and then enabling users, whether it’s department heads, physicians or nurses, to be able to access that data and drill into it, and then help them to make better decisions, whether that’s around productivity, or that’s around care decisions. We’re focused on putting that power in their hands, instead of the old way of doing things which entails calling IT and getting a report a few weeks later,” he says.

Looking at the Tampa Bay market that BayCare Health System serves, the region is known for attracting “snowbirds,” or retirees who visit southern states like Florida in the winter, and, according to an article in the Tampa Bay Business Journal, citing data from the U.S. Census Bureau, the population in the seven counties in Tampa Bay has gotten older since 2010. Overall, the “65 and older” population in Tampa Bay increased 10.4 percent compared to only 0.79 percent for the “under 18” population. According to Thompson, these demographic trends don’t have a significant impact on the health systems’ enterprise-wide digital strategy.

“I think years ago maybe we thought about technology being more age-specific. Now, we’re seeing people use technology across the board. I was looking at telemedicine stats, and it’s not like we see all the Millennials using telemedicine; we’re seeing telemedicine use across ages,” he says.

Thompson describes the Tampa Bay healthcare market as a “fairly collaborative community. “We tend to interact and know what each other is doing and I think, largely, try to put the patient first. We’re still diverse in some of our technology. I think there is room for opportunity, not just in my market or in Florida, but across the country to have better sharing of information, and it takes us back to our first topic. I think some of the things that Apple is doing is going to help drive things like that,” he says.

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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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