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How CIOs Can Lead the Charge in IT-Enabled Patient Engagement

July 25, 2017
by Heather Landi
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As healthcare has become more digital, it has provided more opportunities for patients to be engaged in their care, whether through pa­tient portals or mobile apps. In the broader sense, as healthcare continues to evolve from a fee-for-service to a value-based care payment model, many healthcare leaders agree that patient engagement is going to play a critical role. The more involved and invested patients are in their own healthcare, the greater the likelihood for successful care outcomes, and this patient engage­ment piece is paramount as patient care organizations increasingly take on more risk.

The current picture of patient engagement activities and strategies in healthcare organizations is a mixed outlook. The Office of the National Coordinator for Health IT (ONC) reported in 2015 that about 7 out of 10 hospitals let patients view, download and transmit their own health information. A 2016 report from the American Hospital Association found that 92 percent of hospitals offer patients the capability to view medical records online.

In February, CDW Healthcare released its 2017 Patient Engagement Perspective Study to explore the drivers, challenges and influences for patient engagement and that study found that 70 percent of patients say they have become more engaged in their healthcare during the past two years, up from 57 percent in 2016. What’s more, 74 percent of patients said they joined a patient portal offered by their healthcare provider, up from 45 percent in 2016, while 69 percent said they are speaking percentage said they are accessing healthcare informa­tion more frequently.

When asked what motivated them to become more engaged with their healthcare, patients said their top two drivers were greater online access to personal healthcare records and access to online patient portals, the CDW study found.

From the provider side, the study also found that 66 percent of providers noted a change in their patients’ level of engagement with their own healthcare. Seventy-one per­cent of providers surveyed said improving patient en­gagement is a top priority for their organization, which is up from 60 percent in 2016, and 80 percent are working on a way to make personal health­care records easier to access, a large increase from 67 percent who said the same in 2016. When examining providers’ motivating factor for patient engagement efforts, 67 percent said it was an important part of im­proving overall care, while 56 percent cited technology advancements and slightly more than half cited mean­ingful use requirements.

According to that study, patients noted that commu­nication is key to engagement and technology is a tool that can be used to give patients access to information and expand interaction. Ninety-five percent of patients responding to the survey said they have experienced benefits from engagement with their personal health­care information online.

However, challenges remain, as highlighted by the survey, as just 29 percent of patients said they would give their healthcare providers an “A” for their use of technology to interact with and engage patients. Ad­ditionally, a survey by NEJM Catalyst, which is part of the NEJM Group that produces The New England Journal of Medicine, found that most healthcare or­ganizations are still in the pilot or planning stages for the next wave of patient engagement, such as using patient-generated data, social networks and wireless/ wearable devices.

When asked about the current status of patient en­gagement efforts among patient care organizations, Doug Thompson, senior director, research at the Wash­ington, D.C.-based Advisory Board Company, says, “It’s better than it used to be. Traditionally, patient engage­ment was not something that was driven by the health system, it was something that might happen between the doctor and patient. In the last five years or so, health systems have been interested in patient engagement for a variety of reasons and they have improved it substan­tially. If you ask hospital and health system executives, they’ll say, ‘Yes, we need to have engaged patients, be­cause we’re not paid for really sick patients coming into the hospitals and getting a lot of treatment, we’re paid for keeping patients well. And, if we’re going to do that, it’s essential for us to engage with the patient so they can promote their own good health and have less utili­zation.’ The state of the industry has improved, but it’s not fantastic.”

Considering the challenges facing healthcare lead­ers in their efforts to improve patient engagement, Hal Wolf, director, information and digital health strategy at the Chicago-based Chartis Group consultancy, says, “Healthcare systems are moving simultaneously towards strategies to deliver population health and personaliza­tion. Understanding that one size does not fit all is a crit­ical learning in patient engagement. Sometimes systems are focused on the individual patient but often there is an extended support system that has to be engaged. Patient segmentation is new to healthcare, so borrow­ing lessons from other industries, like finance, media and retail, is critical.”

STRATEGIC PATIENT ENGAGEMENT, AND THE ROLE OF I.T.

As health system leaders de­velop patient engagement strategies, they need to be focused on what they are try­ing to accomplish and for what reason they are develop­ing their strategy, Wolf says. Health system leaders should ask: “Which patients do they serve best? What cohort is prevalent in my market? Which short- and/or long-term re­lationships with patients and providers are needed? This is just the beginning of the questions that need to be asked,” Wolf notes. “Gaining a clear understanding of where their market is headed and how they want to be positioned is just as important in patient engagement as it is in every segment of cus­tomer relationships.”

As technology and IT are foundational to many pa­tient engagement initiatives, whether patient portals or mobile apps, CIOs will need to offer their expertise in the latest patient engagement technologies.

“Patient engagement initiatives span many areas of a healthcare organization, requiring the participation and support of marketing, patient access, various clini­cal departments, revenue cycle and others, including IT. The IT function, led by the CIO, can be a point of integration for these stakeholders, helping them to de­fine their goals, and working with them to design IT-enabled solutions,” Alan Perkins, a principal with The Chartis Group, says.

To this point, Wolf projects that the development of customer relationship management systems (CRMs) will become increasingly important as the expectations of personalized care and connectivity rises. He adds, “But the successful implementation of a CRM requires work­flow changes across the entire organization.”

Hal Wolf

What’s more, beyond being involved in the imple­mentation of patient engagement initiatives, the health system or hospital CIO can be a change leader, Perkins says, “staying abreast of new developments in patient engagement technology that he or she can bring to executive leadership for consideration.” He also adds, “Failing to engage in these ways puts IT at risk of be­ing sidelined, relegated to merely the ‘nuts and bolts’ of software and hardware maintenance.”

Perkins notes, “A related challenge is understanding the unique needs which these different categories of pa­tients have, and then designing and implementing mea­sures to assist them. For example, for some patients, a portal that enables online bill payment and appoint­ment scheduling may be all that is needed. For others, a smartphone app into which the patient enters their vi­tal signs following discharge from the hospital, coupled with a process for alerting a nurse to contact the patient when those vital signs are out of expected ranges, could be an effective intervention. Different patients have dif­ferent needs, and thus multiple engagement initiatives are needed.”

Alan Perkins

Thompson agrees that a “blended portal/app strat­egy” is needed, as portals are effective with loyal “consumers” of the health system’s services, but apps are more useful for patients who see providers at dif­ferent systems.

Many clinical leaders believe that giving patients access to their health information is an easy-to-access online format can be pivotal to getting pa­tients more engaged in their own care. At Phoenix-based Maricopa Integrated Health System, Anthony Dunnigan, M.D., chief medical informa­tion officer (CMIO), was in­volved in a health system-wide effort to increase patient par­ticipation in the health system’s personal health record (PHR) across its clinics and ambulatory providers. When Dunnigan joined Maricopa health system three years ago, the patient adoption rate of the PHR, which is pro­vided by Epic’s MyCharts app, was around 9 percent, he says.

Clinical leaders worked with the IT team on a project to develop a patient sign-up process that is incorporat­ed into the workflow of medical assistants at the clinics. In 15 months, the health system increased the patient adoption rate to 45 percent.

“The real key to the success of this project, rather it being an IT-led effort or initiative, was to get the ambu­latory leadership at the very top permeating three rungs down to really make this a project led by them, and have them drive the consensus on how they were going to get the adoption accomplished via a workflow and that it was reproducible in each clinic. IT took on more of a faciliatory role,” Dunnigan says.

Thompson contends that one of the key challenges facing CIOs with regard to patient engagement initia­tives is a lack of clarity on the part of clinical and opera­tional executives as to what the health system wants. “If someone on the clinical side says ‘There is a proj­ect to engage with patients and, CIO, help us out and do something with IT to help us engage with patients,’ that’s pretty fuzzy. So, that’s one problem; they are not getting clear enough communication or priorities from their counterparts.”

Doug Thompson

He adds, “Instead, the CIO should ask ‘Tell me exactly what do you want to accomplish, what sort of conversa­tions do you want to have, and what sort of influence do you want to have over the behavior of the consumer or patient? And, then let’s work together to figure out how IT can help you do that.”

EXPERTS URGE CIOs TO FOCUS ON THREE PRIORITIES

With regard to leveraging technology and IT for patient engagement efforts, Thompson says health system CIOs and other executive leaders should focus on three pri­orities. The first is establishing a simplified online con­sumer platform, or, essentially, to be “Amazon-like” in the ease of interaction. Second, creating a ROI for loyal consumers of the system’s healthcare services, such as reward programs or subscription-based memberships. The third priority, he says, is cultivating consumer cham­pions by demonstrating that the health system cares about their best interests, such as offering virtual visits or a money-back guarantee program. “This includes us­ing CRM systems as a database of information about particular consumers and what they care about, and get­ting to know them in a very detailed way, and giving them what they want,” he says.

There are several leading health systems that are stra­tegically moving forward on patient engagement ef­forts in many of these areas. In 2015, Geisinger Health System launched its money-back guarantee program, called Geisinger ProvenExperience, to refund patients who reported a poor health care experience. In an ar­ticle in NEJM Catalyst, Greg Burke, M.D., Geisinger’s chief patient experience officer, wrote that, one year af­ter the program’s inception, the total refund request for the year was about $500,000.

Burke wrote, “Now, a year after the initiative began, we have learned that ‘making it right’ for patients fol­lowing service failures has increased the amount of grievances received, has cost a relatively small amount of dollars in relation to the system’s budget, and has added to the overall process of care improvement as problems in service delivery have been discovered and addressed.”

Thompson also points to a number of other health systems that are demonstrating innovative and effec­tive patient engagement efforts, such as Oakland, Calif.-based Kaiser Permanente, “they are doing a fantastic job of connecting with patients online”; New Orleans-based Ochsner Health System operating in southeast Louisiana, as well as several health systems that are effectively using IT to support care navigator services for patients.

Kaiser Permanente executive leaders announced last year that half of the health system’s patient visits are done virtually, whether via smartphone, videoconferenc­ing, kiosks and other technology tools. With regard to Ochsner Health System, Thompson says, “They have a digital medicine program that engages patients to par­ticipate in their own health, so that’s patient engage­ment by tracking relevant indicators through digitally connected devices that the patients and consumers have in hand.”


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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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