Have we finally turned the corner toward meaningful patient engagement?

Jennifer Lundblad, President & CEO, Stratis Health

Over the past decade, there has been a lot of talk about consumerism and engaging patients and families in health care. Yet many clinicians, health care organizations, and patients have not had the knowledge and resources (and in some cases, the motivation) to know how to move forward.

Now, we are finally turning that corner. A number of things are converging which indicate the shift toward patient engagement is underway…

Health care delivery organizations are beginning to have some of their payment based on how well their patients perceive their care to be; the most powerful example of this is CMS’ Hospital Value-Based Purchasing Program, launched last year, which rewards hospitals for excellent performance, of which the HCAHPS (Hospital Consumer Assessment of Health Care Providers and Systems) score comprises nearly one third of the total performance rating for a hospital. In addition, the current EHR Meaningful Use stage 1 criteria include items that emphasize the importance of patient engagement, including requirements for an after visit summary for patients after each health care encounter. More focused and intense requirements are anticipated in Stage 2, including online access for patients to their information

Beyond payment and requirements, we are seeing and reading more and more about patient engagement. It is striking and timely that the entire February 2013 issue of Health Affairs is devoted to patient engagement…entitled “New Era of Patient Engagement.” Articles and topics range from shared decision making, to the linkage between patient activation and health care costs, to new models of more patient-centered care delivery.

It is an exciting time to be working to improve quality in health care, and to reach the long overdue turning point toward patient engagement as the next “blockbuster drug.”

2014 EHR Certification – Will all vendors stay the course?

Phil Deering, REACH Regional Coordinator/HIT Consultant

As one of REACH’s Regional Coordinators I sit at a nexus of consultant/client activity. So I hear lots of “chatter” about meaningful use, EHRs, workflows, etc. One of the REACH consultants forwarded me the following (heavily de-identified) email:

We received notice from (our EHR vendor) on 1/31/13 that they are sun setting our product. They will discontinue development on 6/30/13 and they will discontinue support 6/30/14. Needless to say we have to start looking for another EHR/PM. Lucky us, huh? ….. Never a dull moment in healthcare!

The vendor didn’t say so, but it’s reasonable to expect that the requirements for 2014 EHR Certification that have emerged as part of the Stage 2 final rule have caused this vendor to close up shop.

To be a certified EHR in 2014, vendors will need to meet a large number of new requirements including 15 that are completely new (provider notes, family health history, access to images, view, download and transmit information to 3rd parties, safety enhanced design and data portability to name a few) and 23 revised criteria. Given the stringent new requirements, it is not surprising that some vendors would get out of the business.

On the other hand, features of 2014 Certified EHR Technology actually invite innovation and encourage niche vendors to get into the market. Those features are the new modular design of EHR’s the 2014 specification allows and the requirement of data portability. All EHR’s must have base functionality that ensures safety, quality and exchange of data. However, with 2014 rules, an EP does not need to purchase technology that has features the EP doesn’t need in their practice. So, for example, a dentist could purchase an EHR that doesn’t have immunization registry upload. This is good for dentists (they don’t need to buy features that they don’t use) but also good for niche vendors (they don’t need to build or charge for features their customers won’t use). Data portability will make it easier for information to be passed from one EHR to another allowing for this modular construction and lowering the bar for migration from one vendor to another. 

Predicting the future is dangerous, but it’s my opinion that the 2014 certification requirements will result in additional choices for specialists, at the same time, we may see fallout among the small soup-to-nuts vendors that appeared in such great numbers at the beginning of the push for MU.

For a comprehensive review of the final rule on 2014 CEHRT  read this document prepared by CHIME.

Power of Collaborating in Reaching and Maintaining MU

Sarah Tupper, MS, RN-BC, LHIT, CPHIMS, REACH HIT Consultant

Are we born wanting to collaborate? I don’t think so. Most infants I have known are pretty self-centered (which is totally appropriate). I don’t think my houseful of teenagers is as collaborative as they were when they were in elementary school, either. So, based on my own experience, I would say, no, that the appreciation for, and desire to collaborate comes with experience. Some people naturally prefer to work in groups, while others prefer solitary work. Collaboration is different. Collaboration refers to working together, or jointly to accomplish a shared goal. I believe that part of becoming more and more collaborative is realizing and appreciating that others have gifts that I am not blessed with and never will be, and I certainly would want them on my team if we couldn’t be successful without their particular gift! I believe that in order to be a true collaborator, one has to become humble, and admit, that indeed, there isn’t much that I can accomplish all by myself.

As I write this, a couple of sayings come to mind: “a cord of three strands is not easily broken”, or “two (people) are stronger than one”. For the past two years, I have had the privilege to facilitate a collaborative group through REACH. The participants are similar in organizational size, are located geographically close to one another, and they share the same EHR vendor. This group has been through a lot together…implementation of their EHR, working through snags in the meaningful use (MU) reports out of their EHR, sharing workflow “a-ha’s” as they worked toward meeting the MU objectives. They have even visited each other’s sites to observe workflows, report set-up, and other sharing. There was a time when this group was able to persuade their vendor not to charge extra for a piece of functionality that was needed to meet MU. They were successful! They shared a common goal, set forth to achieve it by leveraging the expertise of each individual, and collectively, although small, they continue to be mighty in their achievements. Now, that’s collaboration!

I believe that the outcomes of this group would not have reached the level they have without the amount of collaboration they have enjoyed and been willing to maintain. I assumed that this group might want to disband after the majority of the participants successfully attested to their first 90 days of Stage 1 MU. Instead, the group decided to continue to collaborate, just less frequently. I believe that strong bonds are formed and will be naturally maintained when people successfully collaborate through challenging situations. It reminds me of my days practicing as an RN in acute care. The clinical situations that had the best outcomes were those where all involved (the patient, nurse, respiratory therapist, physical therapist, occupational therapist, pharmacist, physician, dietician, family members, spiritual care) humbly admitted that they couldn’t save the patient on their own, rather, they “pooled” their special areas of expertise and life experience, collaborated to plan, intervene, and support a common goal: assisting the patient to a higher level of functioning. That’s when collaboration can make the difference between life and death! For more stories about the power of collaboration to meet MU, I recommend a visit to the HealthIT.gov website.

The 8 Commandments of Meaningful Use Penalties for Eligible Professionals

Phil Deering, REACH Regional Coordinator/HIT Consultant

No one I know, or can imagine knowing, has time to read all the blogs, tweets, and other forms of information that address meaningful use. However, there is a lot of great information to be had in the blogosphere. Jim Tate, a frequent blogger on HITECH Answers has been an authoritative source, who keeps information interesting and pithy. I found his recent post, The 8 Commandments of Meaningful Use Penalties for EPs, to be really useful. REACH would love to hear your thoughts on it as well.

HIT Evolution and Meaningful Use Stage 3: From Finance IT to Patient IT

Joe Wivoda, REACH HIT Consultant

The evolution of information technology (IT) in health care has been remarkable, and very similar to what other industries experienced in the 1980's and 1990's. Health care is definitely behind manufacturing, banking, education, and other industries when it comes to using IT, but we can learn from those industries to (hopefully) leap ahead. The new Meaningful Use Stage 3 Request for Comment made me realize that IT professionals working in health care should perhaps consider this and begin to call themselves Patient Information Technology workers instead.

Meaningful Use Stage 1 started the trend with the requirement that hospitals and clinics provide patients with an electronic copy of their health information upon request. Funny thing is that few people requested it! Medical Record staff did not make it a clear option for patients requesting their information, and staff did not realize the data was displayed in a user-friendly way. It was okay to provide patients with a paper copy of their chart, but some organizations decided that it was necessary to encrypt their electronic copy. This is a misunderstanding, and provides yet another barrier to engaging patients in their care.

Stage 2 took a new approach to patient engagement: Portals and Personal Health Records (PHRs). Not only do half of the patients need to be set up in the portal or PHR, but 5% must actually access and use the information. Like it or not, we will need to get patients used to accessing their information online. Banks have been able to do it, and so have schools, car dealers, and just about every other industry. Heck, I know exactly when my UPS package arrives at my front door via an email, but it takes several days for a phone call from my physician to tell me my lab test was normal. UPS did not need a government-funded incentive program to begin to offer this service, they did it because customers asked for it and their competition was doing it.

The proposed Stage 3 measures that are currently out for comment take patient engagement even further. Patients will have to have the ability to request amendments to their records and submit patient-generated information. By 2014 I expect there will be blood glucose monitors that connect to your smartphone that will automatically update a designated portal or PHR. Imagine the benefits to patients! Imagine the concerns from providers ("How do I know that is accurate?").

Health Care IT professionals need to take a lead role in creating excitement around patient engagement technology. Until recently, HIT was primarily Finance-IT, and with meaningful use it has finally become true HIT, but I argue we need to be Patient-IT. If we take a patient-centered approach to everything we do in IT we will make a real impact on the health of patients. If we took a patient-centered approach wouldn't the bills be easier to understand for the average patient? If we took a patient-centered approach wouldn't there be a portal that was user-friendly? Wouldn't we have a help desk for patients to call to get help in understanding how to log in and understand their information? Wouldn't we have higher quality, safer, more efficient processes if we put the patient at the center of our implementations and not the physicians and staff?

Starting today I am going to consider myself a Patient Information Technology worker. It will take a while for me to get used to calling myself that, but I will start today. Will you join me?

Eligible Professionals Working in Multiple Organizations: A complex area of meaningful use

Rich Gehrman, REACH HIT Consultant

Attesting for eligible professionals (EPs) who work in multiple organizations is an especially complex area of meaningful use (MU). It affects large institutions, independent practices and safety net clinics alike. Key issues include:

1. Which organization(s) should get an EP’s incentives and which one should attest?
2. What is the easiest way for institutions to assemble attestation data?
3. What if organizations are attesting to different menu or quality measures?

Recently REACH has worked on these questions with a collaborative of large health care systems in Minnesota. Here are some of the lessons learned.

Know Where Providers Work. Even full time employees may moonlight in urgent care or volunteer at a safety net clinic. Since combined data from all sites is needed to attest for MU, employers need to know where else their providers work. Ideally, institutions gather as much information as possible before asking EPs to complete any forms. For example, find what HR and credentialing staff already know, and check federal websites for other institutions that have proxies registered for individual EPs. Institutions also use written agreements asking EPs to provide and update information about other work.

Prepare to Share. Set up data collection and reporting procedures so it will be as easy as possible to give and receive data about a provider’s encounters in other institutions.

Separate Data from Dollars. Questions about which institutions receive which shares of an EP’s incentive payments are best addressed in a different forum from issues about assembling data needed to attest for MU.

Keep an Eye on Medicare Penalties. Some institutions may not be ready to provide data that specialty practices such as radiologists, cardiologists and anesthesiologists will need to attest to MU. For example they may not build out their EHRs to produce appropriate clinical quality measures for these groups. Conversely some specialists may not realize that they will be exposed to Medicare penalties if the institutions they work for do not plan with them in mind. It is in the interests of both partners to start talking about Medicare penalties quickly.

Remember: A provider can't split up their incentive and designate shares to more than one organization. All of the incentive has to go to just one organization. So when a provider signs over their incentive to more than one organization the last one to enter their identifying information gets the incentive. Identifying information includes the organizational NPI and their Tax ID or Employer ID.

An attestation isn't valid unless the organization doing the attesting enters numerators and denominators from all the places an EP works that have a certified EHR. This will get picked up when the CMS systems see a mismatch between all the places an EP has had Medicaid and/or Medicare encounters and the ones that were attested to. The incentive won't get approved until the attesting organization backs out the incorrect attestation and re-enters a correct one. Not only does this mean they have to make sure they find out where else a provider is working, they need to contact those other organizations and get them to share their data.

Stage 1 Changes Enacted by Stage 2 Final Rule

Reid Haase, REACH HIT Consultant

During the lead up to CMS publishing its Stage 2 final rule for the EHR Incentive Program, the policy makers at ONC reflected on public input and their own internal consideration to streamline aspects of Stage 1 for eligible professionals (EPs), eligible hospitals (EHs) and critical access hospitals (CAHs). What resulted from this were sensible changes, some of which are mandatory for all Stage 1 participants and others that are optional. You’ll need to pay close attention to when each of the changes will be enacted as some started as early as October 1, 2012 for EHs and CAHs, whereas others will be optional in calendar/fiscal year 2013 and then become mandatory for calendar/fiscal year 2014.

Gone is the need to conduct a separate and unique test of HIE (replaced in Stage 2 through other objectives that accomplish exchange of patient information) and the ‘yes/no’ attestation question on submission of clinical quality measures was eliminated. You’ll also see that the clarifying wording of some objectives was changed to deal with claiming exclusions, such as in the menu set to ensure that participants were making the best attempt at accomplishing five of the 10 measures rather than claiming an easy exclusion such as for syndromic surveillance which many states are not prepared for.

Conversely, a new exclusion was provided for e-prescribing. Some providers are not able to send an electronic script as a pharmacy accepting the electronic prescription is not within a sensible distance (chosen as 10 miles in the new wording). Feedback was also incorporated for the charting of vital signs including blood pressure, height, weight and specified age ranges. Providers will be able to claim exclusions for those parts of the objective that do not make sense to their practice or patient population including age ranges.

The objective to provide electronic access or an electronic copy of a patient’s record has also been modified based on the Stage 2 requirements, specifically those surrounding the use of patient portals.

We’d recommend that you take a few minutes to review the changes in detail. They are outlined in a succinct, six page PDF document that you can download via the link below.

Stage 1 Changes Tipsheet > 

Stage 2 Overview Tipsheet >