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As the Stakes Get Higher, One Consultant Examines the Industry’s Slow Progress to Meet Consumer Expectations

June 29, 2018
by Heather Landi
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Just how far behind is healthcare when it comes to consumerism?
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Just this week came news that Amazon made another move into the healthcare space with the acquisition of PillPack, a Boston-based online pharmacy startup. This follows Amazon’s move earlier this year to partner with Berkshire Hathaway and JPMorgan Chase & Co. on a healthcare initiative to improve satisfaction and reduce costs for their companies’ employees. Just recently, the organizations tapped Atul Gawande, M.D., as CEO of the initiative.

For healthcare executive leaders, the stakes are getting higher in an era of growing consumer expectations and new competitors focused on access, convenience and low price. According to a new report by Kaufman Hall, a Skokie, Illinois-based provider of enterprise performance management software and consulting services, senior executive leaders at healthcare provider organizations are aware of the need to adopt consumer-centric approaches, but are struggling to implement these approaches. What’s more, the progress that is being made is not occurring fast enough to keep pace with more advanced industries.

Kaufman Hall’s 2018 State of Consumerism in Healthcare: Activity in Search of Strategy report is based on a survey of425 executives at 200 hospitals and health systems nationwide The survey examined four areas—access to care, consumer experience, pricing and developing consumer insights. Healthcare leaders across the country are placing greater emphasis on consumer-focused strategies, particularly around access to care and consumer experience. Yet, despite these efforts, initiatives generally lack foundational consumer-focused insights, the necessary analytics for success, and have not overcome longstanding problems with the consumer healthcare experience, the survey found.

In the report, one survey respondent said, “The traditional healthcare industry is so far behind in terms of meeting, much less anticipating, consumers’ expectations, that I fear for our ability to adapt quickly enough to remain relevant.”

According to Kaufman Hall’s Healthcare Consumerism Index, which categorizes organizations into four tiers, there are few top performers when it comes to consumerism, despite broad awareness of evolving consumer expectations. Only 8 percent of organizations are rated Tier 1 performers for aggressively pursuing consumer-centric strategies. These organizations outlined a consumer focus roadmap early on that has evolved over the years. Of the survey respondents, only 23 percent are rated Tier 2 performers for piloting consumerism initiatives and identifying needs relative to the organization’s overall strategy.

The majority of organizations, about 70 percent, are in Tiers 3 (52 percent) and Tier 4 (17 percent), indicating that they either have not yet begun, or are in the very early stages of their consumerism efforts. Compared with last year, a significant number of organizations have moved from Tier 4 up to Tier 3, but the percentages in Tiers 1 and 2 are relatively flat, according to the report.

In an interview with Healthcare Informatics’ Associate Editor Heather Landi, one of the report’s authors, Dan Clarin, senior vice president in Kaufman Hall’s strategic and financial plannig practice, discusses the healthcare industry’s progress to become more consumer-centric, the biggest challenges facing healthcare executives in this effort to meet consumer expectations, and the growing urgency for change as huge new competitors jump into the provider space. Below are excerpts of that interview.

What are the biggest takeawaysfrom this survey?

One of the things I would point out is that the level of interest in the topic of consumerism, particularly how healthcare providers can become more consumer-centric, is continuing to increase. Compared to last year, we saw a 60-percent increase in the number of organizations that completed the survey. The level of activity that we are seeing among healthcare providers is growing as healthcare providers have more initiatives underway, especially in the areas of trying to improve the customer experience and increase the accessibility of care; a lot more activity underway than even a year ago. The third point is that this continues to be a difficult area for healthcare providers. In some of the results of the survey, indications are that they’ve not been able to make as much progress as they’ve hoped, and they are behind in certain areas, such as pricing and building capabilities around generating a better understanding of the consumer.

Are healthcare organizations under pressure from the entrance of new competitors into the provider space, using the CVS Health and Aetna merger as an example?

Absolutely, and I think they are feeling pressure from a few angles; certainly, new entrants and companies that they may not have viewed as a potential threat in the past, such as CVS Health and Amazon. The competitive landscape is shifting and they are feeling that and paying attention to that. There’s a lot of interest and attention, among healthcare providers, of the employer community as well, just in terms of how employers are changing benefit design and putting more incentives on consumers to make decisions about their healthcare. And, there’s the consumers themselves and the level of awareness of changing consumer expectations, whicht is certainly increasing among healthcare providers. There’s an expectation and understanding that the way consumers navigate the rest of their daily lives with their smartphones and Internet, that those expectations are being translated to healthcare. And, there’s an understanding that, often, consumers are disappointed by healthcare, because they are required to fax hard copies of documents to their doctor’s offices when haven’t seen a fax machine in their lives in 10 years.

The survey findings indicate that consumer-oriented capabilities at healthcare organizations are on the rise, yet only 8 percent are top performers. What does this indicate about the state of consumerism?

The shift of providers from Tier 4 to Tier 3 is reflective of the increased activity around consumerism. What we’ve seen is that more and more healthcare providers are doing pilot initiatives, at least doing something to try to be more consumer-oriented, whether it’s opening up new physical facilities or trying to fix some of the customer experience pain points around things like billing or wait times. We’re seeing more activity and effort, so that’s the move from Tier 4 to Tier 3.

The stagnation around Tier 2 and Tier 1 is a reflection of the fact that a lot of this activity is not clearly translating to results yet, for a few reasons. One is they haven’t been at it all that long, at this point. Many organizations are just getting started with these initiatives. What’s more, many healthcare providers are finding, through this effort to be more consumer-oriented, that they are having to measure success differently than they have in the past. A lot of healthcare providers’ measurements in the past have been very operational-focused and around the clinical operations and the clinical quality. Measuring how they’re doing with consumers, how they are generating loyalty and repeat visits, and share of spend; these ways of measuring how they are doing with consumers, these are not things that healthcare providers have a lot of experience measuring.

Healthcare providers have been slow to adapt because they’ve never had to be consumer focused in the past. This shift requires a new mindset and new way of thinking that go beyond traditional approaches.  This is really hard work and it’s hard to see the payoff right away. Even if, as a management team, you believe this is the right way to go, convincing all the different stakeholders—the physicians, the operational leaders, board members—convincing them this is the right thing to do, and then developing a plan and executing that plan, it’s hard and it takes time. The traditional way of doing business for a long time has been successful, especially for the large health systems that have been successful and have grown over the past 20 years. For them to try to fundamentally change the way they have been doing business, even if they are seeing some of these risks and recognizing some of them as being very real, it’s hard to fix [that way of doing business] when it may not seem fully broken at this point.

With regard to enhancing access to care, are healthcare providers moving forward with more innovative approaches in this area?

We see activity increasing, but organizations continue to be focused on traditional, “brick-and-mortar” approaches. We’re seeing more traditional thinking about fixing the traditional way of doing things, or fixing what’s broken, rather than coming up with new ways to operate. For example, if you have a waiting room and you understand what your average wait time is in that waiting room, the initiative might be around reducing that wait time. However, more innovative approaches to access are less common, where healthcare providers are focusing instead on ‘Why do we have a waiting room in the first place? Is there a way that we can totally eliminate waiting?’

Howe can healthcare executive leaders move forward more effectively on consumer-oriented strategies?

It’s a huge challenge for healthcare providers. They are bombarded on a daily basis with everybody’s recommendations and sales pitches on the latest mobile app, the latest digital technology that’s going to solve their problems; being able to prioritize that is a huge challenge. Effective consumerism strategies are built on a foundation of consumer insights and analytics, yet most organizations continue to struggle in this area. This is around building the capabilities and the resources internally at a healthcare provider system to develop a better understanding of what the consumer wants and needs, and then use that to inform your prioritization.

My recommendation to healthcare organizations is that if you want to know how to prioritize, go ask consumers and listen to consumers as to what they think is important and what are their biggest pain points, then use that to prioritize the initiatives and the digital tools you invest in. What we saw in the survey results is that most providers have not built those capabilities internally around better understanding the consumer. You need that understanding of the consumer first. Otherwise, there is a risk and a temptation is to see all the options that are in front of you, whether it be digital tools, a new urgent care center, a video visit solution, and then start to pick and choose among those options because you feel you must do something to be more consumer-oriented, rather than taking a step back and saying, ‘What does the consumer actually want?’ and using that to prioritize your strategy.

The survey also indicates that only 5 percent of healthcare organizations are aggressively pursuing pricing strategies and price transparency. Is this area an overlooked opportunity?

Before I came to Kaufman Hall, I was with Walgreens, so clearly, in the retail space, pricing of products is a very serious and complex discipline. Millions and millions of dollars are made and lost on pricing decisions. Coming into healthcare, I noticed that there has not been much effort or resources focused around two big questions around pricing decisions: What should our prices be? And, how do we communicate those prices to consumers? There are things that are commonplace in other industries, such as understanding the elasticity of demand for certain services and how much does demand or preference change based on changes in pricing. If you look at the survey results, only 11 percent of respondents said they have done that kind of work before. Pricing is an area in particular, especially with the rise in high deductible health plans and more consumer decision-making, that the industry is going to need to do some catching up.

Overall, the survey shows an increase in activity designed to improve consumerism performance, however, the rate of progress is still not fast enough to catch up with more advanced industries, and when I say more advanced, I mean industries that, for a long time, have been more consumer-oriented. The name of the report, “Activity in Search of Strategy,” reflects that; we’re seeing this increased level of activity, but we’re not seeing the level of consumer-informed prioritization that we would like to see going forward.

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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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