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IT Innovation in Healthcare: Breaking Down the Barriers

August 10, 2016
by Rajiv Leventhal
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In recent years, there have been various areas of amazing advancements in healthcare IT. But, as costs continue to rise and with an aging population and an explosion in chronic disease nationwide, more transformation is needed.  

To this end, as Healthcare Informatics Editor-in-Chief Mark Hagland wrote recently, regarding the Health Affairs estimation that U.S. healthcare spending will rise from $3.3013 trillion in 2014 to $5.631 trillion in 2025, “that figure meets the day-to-day working reality of CIOs, CMIOs, and other healthcare IT leaders, in medical groups, hospitals, and health systems. Because, in order to bend that five-and-a-half-trillion-dollars-plus annual expenditures curve even a little bit, will require a massive investment in, and successful implementation of, excellent health information technology. What’s more, it will require the extreme optimization of healthcare delivery and administration processes, using those IT tools, solutions, and systems. U.S. healthcare can simply no longer afford to be a trillions-of-dollars-a-year ‘mom and pop shop’-type cottage industry.”

Indeed, despite healthcare’s size and growth rate, the sector was long considered an impenetrable, or at least an unattractive, target for IT innovation—but that mindset has shifted. Technology giants such as IBM and Microsoft are more often partnering with providers to improve the healthcare delivery process, while attempting to also bend the cost curve. But, these kinds of partnerships are mostly still in infancy stages.

According to Munzoor Shaikh, a Chicago-based director in West Monroe Partners’ healthcare practice, there are multiple buckets of IT innovation in healthcare, though most providers are still in the very early stages of partaking in them—if they are at all. Shaikh, who has more than 15 years of experience in management and technology consulting, with a primary focus on managed care, health insurance, population health, and wellness, spoke to Healthcare Informatics Managing Editor Rajiv Leventhal about these innovation areas, the sector’s biggest challenges when it comes to technology advancements, and what the future has in store. Below are excerpts of that discussion.

Munzoor Shaikh

The mindset around IT innovation in healthcare seems to be shifting. Can you explain why this might be?

Well, I think there are several areas of innovation in healthcare, and we can start with patient access to care. We are in the midst of a digital transformation, and while the world has gotten digital, healthcare is a ways behind. Innovation is more than just connectivity and computers and networks; a lot of it is around the model in which you engage the consumer. For example, most healthcare payers have historically not really engaged with the member; their customers have been other businesses. So they are going from B2B [business to business] to a B2C [business to consumer], and there is an organizational shift around IT innovation.

The same thing holds true for hospitals and clinics. We were talking with a clinic the other day about how they view a patient’s journey. If you look at a patient’s journey map, what are the pain points and how can technology solve them? Some of them are very basic, like mobile apps, reminders, coordination of care, coordination of data in the back end, and a big theme that came up was the automation and coordination of services for members. There is that patient access side, and there are things like virtual hospitals, if you will, where you have Skype, which can represent a similar experience as if you went to a hospital or clinic.

The other bucket linked to technology is analytics, and it’s not the computing power and predictive capabilities, but more a function of the U.S. healthcare system—and the world’s healthcare—as they are struggling with data aggregation. One of the key things that a population health company can do, and does, is data aggregation around claims, clinical, social demographic, wearables, all of that data. We have this theme internally that we have reached the age of a measured life—everything that can be measured is, but can we put it to good use? That has more to do with data science.

The third bucket is around consumer facing. We always talk about how Amazon is changing their relationship with the customer, and Amazon knows a lot about me, such as what I like to eat, buy and what books I like to read. They are able to cross reference that and tailor it to my preferences. This sounds cool, but it’s more than cool. There’s a real function to it; a concept of population learning.

When you think about population learning, you should consider what patient learning is. So my doctor can look at me clinically and if evidence-based guidelines say that someone in my age group, sex and ethnic group has these particular conditions, and these are the drugs that will work for me for diabetes, that type of evidence-based medicine does work in theory—but not necessarily at the point of care. So that’s half of the equation, and it hasn’t been solved yet at the point of care, but even if it was solved, it’s only half the equation. The other half is the doctor tailoring treatments and procedures for me given my lifestyle. Do I travel? Do I have kids? Patient learning is learning how I respond to this treatment. If I am not doing it, the doctor can also learn more about me and tailor the treatment to that reason.

Now take that one patient and apply it to a population. Doctors are not doing this well with one patient yet, as it’s only happening in a few places. Extending to a population, it gets even worse. You have to learn how a population in northern Illinois behaves differently than southern Illinois, for example. Whatever evidence based medicine suggests, you have to suggest something on top of that to really learn with that population. There are not enough processes and technology tracking things in place yet to be able to create an iterative, agile process where you administer something and observe the results. And I do think this other half of the equation is one that technology and innovation can solve.

What are providers currently doing in these innovation buckets?

I don’t think providers are doing much of these things at all. They are worried about other stuff, about fighting the fee schedule battle with payers. We talked to one provider who has a ton of cash and a ton of opportunity for innovation, and we asked them how come you’re not doing these things? The answer is that they’re saving every single penny so they can buy up the next hospital so they can have bargaining power against the payer. All of the resources are being allocated to that. The forward thinking provider is definitely thinking about these three buckets, though.

What will have to change for providers to be doing more of these things?

It’s a great question, but I don’t know the answer as it’s hard to predict the future. So long as providers are worried about reimbursement, which they will be for a very long time, this will be a challenge. The only exception to this is that some academic medical centers that already have a strong clinical brand might be doing some of these things. I spoke to one recently that said they want to be the best diabetes center ever, so they’re investing money into IT innovation towards that. I also recently spoke to a provider in the Chicago area who said they never have had a chief marketing officer until now, since they never had to market themselves.

Are you seeing more partnerships between technology companies and healthcare providers to spark innovation?

Not at the level that I hoped for. What I would love to see is a provider buying out a technology company that is completely out of their wheelhouse and then looking to be the next Amazon or Google of healthcare. But that innovation, provider-led innovation, is not happening yet.

 What are some predictions for future trends we’ll see in these areas?

My point of view is that while all of these barriers to innovation exist, there is a great opportunity for providers to become masters of their own destiny. Whether they realize it or not, and I think they do, they are not controlling their own destiny right now. They are just reacting against payers, and that’s why they want to [increase] their purchasing power. So there is an opportunity here to say they will be masters of their own domain, do more self-pay, and be more of a retail service provider. “Gain customers, keep customers, and our customers will pay us because we do a superior service.” They may have to only target diabetics who can afford high cost services for better results, rather than target the entire market. “I can tailor my services to you, so try me out for six months and if you don’t like, you can stop.”

Traditionally, payers capitate the payment to the providers, but some providers are doing what I call “micro-capitation,” going to the patient and saying “You give me a flat rate of X amount of dollars, and I will give you gold, silver, or bronze level services for different levels of guaranteed outcomes for your health.” So the patient becomes the payer, which is closer to the Milton Friedman model of economics; the person who buys healthcare also is the one paying for it, and you don’t see that much today.

The opportunity to go direct to the patient has a lot of potential for IT innovation, process innovation, and even clinical innovation. Providers are getting all kinds of data from people like me, and will be able to go to a health plan pretty soon and say that they have some pretty good data and that they can take capitated risk better than everyone else. Providers being in control of their own destiny because they have the opportunity to do something is the highlight.


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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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