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Patient Engagement Technology: Moving Beyond Patient Portals?

October 6, 2016
by Heather Landi
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Traditional methods of digital patient engagement by healthcare providers typically entail a patient portal where patients can access their health records, look at test results or refill prescriptions. There has been data to indicate patients are interested in digital health tools, such as mobile apps, yet industry data also indicates that patient portal usage remains fairly low.

As previously reported by Healthcare Informatics, a Harris Poll survey released in June found that only 9 percent of 2,000 polled adults use a portal to set up appointments, with 13 percent of millennials using portals to book appointments. The Harris Poll survey found that more consumers are using portals to get test results (23 percent) and to get prescriptions and refills (11 percent). Almost a third of respondents (29 percent) report using a portal to look at their current health data.

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 in order to increase patients’ meaningful participation in their own care. According to that survey, 88 percent of healthcare leaders surveyed said their organizations currently use or have plans to implement a patient portal, but with regard to other approaches such as patient-generated data, social networks and wireless/wearable devices, and it seems most efforts are still in pilot or planning stages.

According to Brian Eastwood, a lead analyst with Chilmark Research, a Boston-based health IT research and advisory firm, the current model for patient engagement—the patient portal—is outdated, does not encourage behavior change and should be replaced with a broader engagement technology model. During a recent webinar, Eastwood addressed the need for broader patient engagement tools and presented findings from a recent Chilmark insight report examining how to use technology for improved engagement.

In the report, Chilmark researchers contend that market pressures as well as government regulations force consumers to take more responsibility for managing their health and paying for their healthcare. However, “effective, easy-to-use tools for helping consumers choose the right high-deductible health plan, find the right in-network physician, and make the healthiest choices are few and far between,” according to the Chilmark report.

Patient portals typically are built by electronic health record (EHR) vendors to serve as patient engagement tools, but compared to other digital tools that consumers use on a daily basis, the patient portal is outdated, according to Eastwood. “Even the most advanced portals pale in comparison to the multimodal experiences offered by familiar firms such as Amazon, Apple, Facebook, Google and Netflix,” he said.

“If you look at the typical patient engagement model at healthcare organization, they implement the portal and hit the bare minimum metrics, and move on,” Eastwood said, while also noting that portals are not optimized for the type of care that organizations want to provide moving forward. Patient portals are typically tied to a health system, not the individual, and don’t encourage behavior change, he said.

“[Portals] are systems are record, they are not systems of engagement. Portals capture information about episodes of care but they are not built for coordinated care and are inadequate for population health management,” he said.

Outlining why current patient portals fall short of meaningful patient engagement, Eastwood said patients with chronic conditions might have 10 specialists and 10 different patient portals and the information in a patient portal does not include what patients do in between care episodes. “It’s a disjointed model and doesn’t encourage engagement. It's not optimal for coordinated care that a lot of healthcare organizations are moving toward in the transition to value-based care,” he said.

Eastwood sees the healthcare industry moving toward a model where engaging with patients as consumers is the first step down a road that includes education, activation and empowerment. “The end goal is to create an environment where patients can change their behavior for the better, feel like advocates and feel a shared responsibility to live healthier lives,” he said.

While there are digital health tools that address the education and activation phase of the model, he asserted there are currently few tools on the market that empower consumers. “The ones that do are outside the larger healthcare system. This is a challenge that a lot of organizations are facing, and will face, as they try to transition to more coordinated care and more value-based care,” he said.

There are a multitude of factors that will make replacing the current patient portal platform with a new technology platform very challenging. According to Eastwood, those challenges include multiple entry points to healthcare, limited IT resources, a long learning curve and healthcare’s perpetual pilot phase for technology innovation.

Additionally, healthcare organizations need to develop engagement tools for patients across the care continuum from healthy individuals to at-risk to simple chronic and then further to episodic/procedural and finally complex chronic/acute patients. “Healthcare organizations really need tools to address these complex patients who are the largest constituents of the healthcare costs,” he said.

One particular challenge facing healthcare delivery organizations in patient engagement efforts is the evolving nature of care teams. Besides the clinical care team, there is also the holistic care team, including mental and behavioral health, physical therapy, long-term care and nutritionists, and then the community care team, which is comprised of home care and non-clinical services, with Meals on Wheels as one example, Eastwood said.

“Consumers likely interact with the community care teams far more often than the clinical care teams. Yet the same time, as you move across this care continuum, use and access to electronic health record (EHR) data diminishes. The community care teams are looking at economic information, personal data, social and behavioral and wellness data. The person scheduling the Meals on Wheels is probably not using EHRs,” Eastwood said. “Healthcare organizations looking to improve engagement and make it more broad need to consider what sort of systems and touchpoints these members of the care teams have and consider beyond the traditional means of accessing clinical data.”

According to Eastwood, a broader engagement model would focus on a collaborative patient health record that builds on longitudinal patient health data including social determinants of health and data from the holistic and community care teams to make the model more bi-directional.

Moving forward, there are a number stakeholders who could drive innovation in developing broader patient engagement models, with the primary stakeholders being patients and healthcare providers, especially those participating in alternative payment models such as accountable care organizations (ACOs) and the comprehensive joint replacement (CJR) bundled payment program as well as integrated delivery networks (IDNs) and even non-traditional care settings such as retail, telehealth and payer-provider organizations. Additionally, payers and providers could drive the innovation including large and self-insured employers and Medicare or Medicaid, Eastwood said.

“Payer organizations and their employer clients who are working with larger populations of members with increasingly diverse care needs and insurance needs see the value for more coordinated care, which begets a more interactive engagement process than the transactional way of doing things,” he said.

Secondary stakeholders include vendors that design EHR systems and care and condition management tools, he said.

Eastwood projects that providers and vendors moving forward to develop a new, broader patient engagement model will likely experience what he called “short-term pain.”

“There are a growing number of entry points and point solutions. Even with consolidation, the point solutions that consumers use to access the healthcare system will get bigger. We need to try to connect to these solutions in some way and integration is the best we can hope for,” he said.

Furthermore, return on investments on such efforts remains a mixed bag, he said. “Shared risk has demonstrated some efficacy but other efforts are too soon to tell. Wellness programs are longer-term investments aiming for the long game, so trying to decide one year out if a wellness program works is not conducive to making the program work,” he said.

Engagement programs and models are still evolving, he continued, and healthcare organizations will need to decide if they are focusing on loyalty to a program or care management. And, providers and payers also have different engagement needs, with payers focused on price, quality and cost while providers are addressing different engagement needs for patients, namely, convenience, education and loyalty. “These are not entirely competing interests, but they are not completely complimentary either,” he said. “Organizations need to sit down and figure out how to bring these strategies together.”

Despite the myriad of challenges, Eastwood also projects that such efforts to develop broader engagement models could, in three years, result in long-term gains. For patients, it could mean access to their collaborative health record and a more seamless, multimodal experience with the healthcare system. “The customer experience will improve,” he said, also noting that patients will have more active participation in their health and wellness and better self-management of their care.

Looking at the market outlook to 2020, Eastwood estimates that in the next three years the industry will start to see the evolution in patient relationship management (PRM) with partial device integration and partial engagement among larger and regional healthcare delivery organizations and midsized payers and employers, though these efforts at integration will still lack social determinants of health (SDoH) data.

By 2020, he forecasts the start of what he called “PRM 2.0” with full device integration and near-full engagement and partial integration of SDoH data. He also projects these efforts will begin to trickle down to small and rural healthcare organizations.

In these efforts to develop broader patient engagement, Eastwood also believes there will be leaders in the industry who will emphasizes customer loyalty along with a push to value-based care with high visibility, large scale patient engagement programs. Then there will be followers, he said, who will emphasize value with a push to care management and their efforts will be medium scale with high volatility. Finally, there will be the organizations he called “waiters,” and these organizations will emphasize strategy and value and will push to grow, or get acquired, and their efforts will be small scale with high uncertainty.

In sum, Eastwood offered a number of recommendations for healthcare organizations to transition to broader patient engagement models.

“For engagement programs to work, you need to align technology, experience and the business model and define the value proposition. For example, if the customer experience is still lacking and your apps are crashing, it’s not going to work and your engagement efforts will fail. So technology, experience and the business model need to be closely aligned,” he said.

He continued, “One of the key ways to do that is to figure out what you’re trying to accomplish with your engagement model. Are you focused on loyalty, on care management or are you just focused on demonstrating that you can engage with your population?”

Once an organization defines its value proposition, the next step is to find like-minded collaborators, “such as vendors of health IT solutions or payers in your area to start making that engagement model a reality,” he said.

Eastwood also suggested that healthcare organizations push beyond short-term convenience. “Push beyond low-acuity care to more coordinated care, and the way to do that is to emphasize a consumer-centric design into engagement solutions you develop and roll out. You need to understand how consumers use them, make it convenient for them in the goals they are trying to achieve and the overall healthcare needs they have, and make it simple without taking away from the clinical efficacy. It needs to be something that they will stick with as much as the social media apps on their phone,” he said.

“That will plant the seed for behavioral change,” he added.

Eastwood cautioned that these efforts will take time while also encouraging healthcare organizations to “think big.”

“A small step is better than no step. And many organizations are in pilot phases to test out new modalities of engagement to see if they work to help drive down A1c levels and increase physical activity, for example. But, at the same time, I think organizations need to look at the big picture. Think about why you are doing these things—the ultimate goal is to help people make better decisions and live healthier lives so they don’t have to spend a lot of time in high acuity care organizations,” he said.



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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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