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KLAS: Early Adopters of Apple Health Records See Immediate Positive Impact

May 8, 2018
by Heather Landi
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In January, Apple announced the launch of Apple Health Records, a new iPhone feature for downloading, aggregating, and viewing patient medical records. At that time, 12 major health systems signed up to be digital health partners as beta testers of the health records feature. In March, Apple tripled the number of health systems participating, from 12 to 39, and announced that the new capability was available to all iPhone users with the latest iOS 11.3 update.

A new report from Orem, Utah-based KLAS Research gather feedback from executives at all 12 of the early adopter health systems that partnered with Apple through the beta process to validate the significance of Apple’s move. KLAS researchers spoke with healthcare executives at participating health systems to gauge their experience, so far, and executives were asked: How soon might it make a difference? What is the experience like so far and what hurdles do providers face? What challenges does Apple face and how likely are they to succeed where others have flopped?

Fifty percent of respondents were CIOS, 17 percent were CMOs or chief medical information officers (CMIOS) and 33 percent were other executives or directors.

KLAS researchers note in the report that Apple’s revelation created a stir for at least a few reasons: Apple is a consumer-oriented healthcare outsider; Apple is attempting to make inroads where peers Google and Microsoft have failed; and the feature has the potential to impact millions of patients given the iPhone’s broad customer base.

According to the report, early participants say that Apple’s move is not just a marketing ploy and that it has both short-term benefits and long-term potential to impact how provider organizations interact with patients and how patients manage their health.

Close to 60 percent of respondents say they expect Apple’s “ready-to-go” patient-record portability to have an immediate positive impact, within zero to six months. Another 33 percent expect to see benefits from the Apple health records feature within six to 12 months. According to the report, one CIO said, “Honestly, there are no hurdles for us. The work effort to turn the app on is measured in days. There is no IT team that needs to do anything fancy or complicated. The wonder of this app is that the lift is tiny and the benefit is huge.”

These executives feel that allowing patients to access personal medical records on their smartphones is a revolutionary idea, one that disrupts current paradigms by setting off a series of small changes that may have major impact downstream. Three of the most mentioned benefits include empowering patients (67 percent), helping solve interoperability (58 percent) and speeding innovation and change (50 percent). When asked how impactful they think the effort will be for healthcare, on a scale of one to nine (most impactful), 33 percent rated the effort a ‘9,’ 11 percent an ‘8’, 33 percent a ‘7’ and 22 percent a ‘6’.

“Immediately, Health Records is expected to help solve the intractable challenge of interoperability by allowing iPhone users to store their health records on a device that is already omnipresent in their lives. This convenience is expected to increase patient satisfaction and also engender in patients an expanding sense of self-ownership and self-involvement in their own care,” the report states. “In the long term, making health records available on the iPhone promises to speed innovation by breaking down the door between healthcare and consumer fields.”

Respondents say that non-healthcare vendors understand patients in a different way and that out-of-the-box research and development from these vendors may result in efforts that motivate and direct patients better than the methods that have historically been available.

According to the report, early participants believe the time is right for Apple to leap over healthcare hurdles—EMR (electronic health record) adoption has never been higher, and thus electronic records have never been as available; smartphones are more entrenched than ever; and interoperability standards (like FHIR) have never been as advanced, the report states. “With historical attention to privacy and a business model that isn’t dependent on selling consumer data, Apple has earned consumer trust. Additionally, their Health Records solution sidesteps most HIPAA concerns because Apple never takes possession of patient data,” the report states.

The report also found that optimistic participants choose a strategic back seat, with most participants viewing the health records feature as an add-on for patient convenience that does little to alter their patient engagement strategy. Most organizations’ formal plans for the health records solution are limited to its most immediate benefit—allowing patients to download their patient record. In fact, 75 percent of respondents cited giving patients access to their data as their plan for Apple Health Records. Half of respondents said they will use it as an additional option for their current patient engagement strategy and 33 percent said they will integrate data into patient care. A quarter of respondents said they will let Apple drive adoption.

Can Apple Scale?

KLAS researchers also looked at next steps and participants indicated that Health Records’ impact will depend on Apple’s ability to scale education, adoption, and data complexity. The KLAS report notes that there are over 2,000 hospital-based health systems in the U.S., and, in order to reach more than one-third of these, Apple will need to expand to EMR vendors beyond their current partners (athenahealth, Cerner, and Epic). According to KLAS data, of all the acute care hospitals in the U.S., only 5 percent are among the health systems that are participating. What’s more, 48 percent of hospitals of non-participating health systems use Apple partner EMRs (athenahealth, Cerner and Epic) and 47 percent of hospitals are currently using other EMRs (Allscripts, CPSI, Meditech).

“In terms of capabilities, participants say that being able to upload data back into the EMR will be vital and that eventually Health Records’ data model will need to support more detailed data than the C-CDA data elements handled today,” the report states.

According to the report, one CIO said, “That is a huge leap from where we were three years ago, and an even bigger leap from ten years ago. I think upcoming versions will take the data that is now on the phone and, with the patient’s consent, import that into a designated EMR to close the loop.”

The KLAS report notes that, eventually, if this general capability is going to benefit all patients in the U.S., it will need to expand beyond Apple to other smartphone vendors. One CIO stated, “If an Android version becomes available that will be a home run for a lot of people.”

Looking ahead, healthcare executives said the biggest obstacles would be to educate both patients and clinicians about what Apple’s PHR means to them. Participants face a similar issue as they attempt to find a place for Apple inside their existing patient portal strategy by differentiating the capabilities and use cases for each tool. One CMIO said that it is going to take some time for his staff to understand what Apple’s tool means.

Time will tell if Apple can scale in signing up more provider organizations and EMR vendors and then deliver bidirectional data exchange and expand Apple’s current data model beyond basic C-CDA elements. The KLAS report concludes that, regardless of the timeline or eventual strategy, Apple has changed the discussion, if not the landscape, of patient and consumer engagement in healthcare.

 

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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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