Beginning in 2011, the Centers for. Patient Experience Should Be Part Of Meaningful-Use Criteria. Defining Meaningful Use

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1 By James D. Ralston, Katie Coleman, Robert J. Reid, Matthew R. Handley, and Eric B. Larson Patient Experience Should Be Part Of Meaningful-Use Criteria Engaging Patients And Families Although currently proposed measures of electronic health record use include several wellestablished indicators of health care quality, we contend that the measures do not go far enough to help ensure the success of engaging patients and families with electronic records. Furthermore, current payment policies that focus on in-person outpatient visits do not support the later stages of secure messaging between patients and providers. Directly engaging patients and families through the use of electronic health records is critical to achieving the technology s promise of improving the health and care of patients. Physicians and patients alike recognize the potential of secure electronic messaging to improve access and care. 4 9 Enabling patients to communicate electronically with health care providers and gain access to medical records may also improve doctor-patient relationships and help activate patients in caring for ongoing health conditions. 4,10,11 At a minimum, most patients want the convenience of accessing some of these online services. Approximately 90 percent of those using the Internet want the ability to communicate electronidoi: /hlthaff HEALTH AFFAIRS 29, NO. 4 (2010): Project HOPE The People-to-People Health Foundation, Inc. ABSTRACT The proposed federal meaningful use criteria for electronic health records include the direct engagement of patients in their care. In this study, we sought to describe the adoption and use of online services linked to the electronic health record at Group Health Cooperative. By August 2009, six years after the introduction of these services, 30 percent of outpatient encounters were actually conducted through secure electronic messaging. Meanwhile, 10 percent of enrollees reviewed medical test results online, while 10 percent went online to request medication refills. These results highlight the need to measure the patient experience as part of meaningful use and to enact policies supporting online and phone communication by patients and providers. Beginning in 2011, the Centers for Medicare and Medicaid Services (CMS) will pay incentives to eligible health care providers and hospitals that demonstrate meaningful use of certified electronic health records. These are longitudinal electronic records of patients health information generated by one or more encounters with care. 1 The proposed definition of meaningful use includes ways not only for doctors to store and retrieve medical information but also for patients and families to gain access to their medical records and thus engage more fully in their care. 2 The first stage of this interaction includes providing patients with electronic copies of medical records. In later stages, as currently proposed, patients would be able to communicate with health care providers through secure electronic messaging and have direct electronic access to medical test results. 3 To qualify for incentives paid through Medicare and Medicaid, providers would also have to provide standard measures of health care quality and electronic health record use. James D. Ralston (ralston.j@ ghc.org) is an associate investigator with the Group Health Research Institute, Group Health Cooperative, in Seattle, Washington. Katie Coleman is a research associatewiththegroup Health Research Institute. Robert J. Reid is an associate investigator with the Group Health Research Institute. Matthew R. Handley is an associate medical director with Group Health Permanente Quality and Informatics in Seattle, Washington. Eric B. Larson is executive director of the Group Health Research Institute. APRIL :4 HEALTH AFFAIRS 607

2 cally with physicians, 12 and approximately half of patients would like Internet-accessible medical records. 13 Many patients also prefer online access for administrative functions, such as scheduling appointments and refilling prescriptions. 14,15 To be sure, some patients worry that relationships with physicians may suffer if online access means that phone and in-person contact is less available. 16 Others are concerned that online communication with providers and access to records may exacerbate existing health care disparities related to race, literacy, socioeconomic status, and other factors. 17 These concerns highlight the importance of measuring and ensuring equitable and open access to all points of care when implementing electronic health records that directly engage patients and families. For electronic health records to successfully engage patients and families, meaningful-use measures should include patients experiences with them. Considerations of the patient experience should include whether care is timely, needs are met, and communication with physicians is satisfactory. National payment policies should be reformed to support providers communication with patients outside of office visits. The Group Health Experience Group Health Cooperative, a consumergoverned, regional integrated delivery system serving Washington State and northern Idaho, invested more than $40 million in 2003 to implement an electronic health record as part of a larger effort to improve access, empower patients, and support care between office visits. Group Health developed the electronic health record to be shared among health care providers and patients over a secure Web site ( 18 A previous study showed that Group Health s early success with these online electronic health record services depended on aligning its practice with a model supporting appropriate access to care when and where it is needed or preferred whether in person, over the phone, or through secure electronic messaging. 19 A subsequent survey of Group Health patients showed improvements in several measures of overall access to care 20 as well as high satisfaction with Web services linked to the electronic health record. 18 Despite these improvements in the patient experience, a study of primary care providers found increasing fatigue and work dissatisfaction, which suggests that the practices needed further reorganization to sustain improvements. 21 In response, in 2006 Group Health piloted a patient-centered medical home redesign that placed further emphasis on engaging patients between office visits through phone calls and online services. 22 In all of the redesign efforts, measurement of patients experiences was critical. Survey results, including experience with the online services of the electronic health record, led to an understanding of whether patients needs were met and could identify areas to target for further improvements in care. In this paper we describe the adoption and use of the electronic health record shared among patients and health care providers over the course of six years of redesign efforts at Group Health. Our findings show steady growth in patients adoption and use of the online services of the electronic health record. By August 2009, 58 percent of enrollees were registered for these online services, and nearly one-third of all patient encounters were through secure messaging. Ten percent of enrollees reviewed medical test results, and 10 percent ordered a medication refill online. The adoption and use of online services at Group Health highlight the importance of measuring patients experiences with electronic health records. They also highlight the value of enabling providers and patients to engage in care outside of office visits. The Study Setting Group Health has more than 350,000 members who receive care through its integrated delivery system. The system includes 26 medical centers and 874 Group Health physicians. Prior to the launch of the patient Web site, Group Health s internal surveys found that enrollees access to the Internet had increased from 24 percent in 1996 to 71 percent in Furthermore, enrollees continued to view their physicians and health care teams as their preferred sources of health care information but were increasingly turning to the Internet as well. 23 Early Electronic Tools Group Health launched its patient Web site in 2000 with the goal of providing online services that patients value and that support patient-physician relationships. Over the next three years, Group Health continued to add services to the Web site. By August 2003, the Web site allowed patients to do the following: (1) exchange secure electronic messages with members of their health care team, including primary care and specialist physicians they had visited; (2) get real-time access to portions of their electronic health record, including laboratory data, problem lists, medications, allergy history, and prior immunizations; (3) obtain after-visit summaries with 608 HEALTH AFFAIRS APRIL :4

3 hyperlinks to the Healthwise knowledge base, a comprehensive, searchable health and drug reference library; (4) obtain medication refills with free shipping to their homes; and (5) schedule office appointments with physicians online. To access the online services of the shared electronic health record, patients were required to complete a registration process verifying their identities. Patients could accomplish this through an online request or by showing a driver s license or passport at a Group Health clinic. Parents or guardians could also access the online services for a child. Group Health provided patients with access to the electronic health record over the patient Web site through a direct link to Group Health s electronic health record, EpicCare. All ambulatory care physicians, nurses, and other providers in Group Health s integrated delivery system used the electronic health record, which integrates clinical communication and information processes into a single interface. That interface includes physician order entry for such items as laboratory tests, prescriptions, and referrals; documentation of all patient encounters; clinical decision support; clinical messaging among physicians; secure online messaging with patients; and automated reminders at the point of care. Expectations Of Providers Group Health providers were expected to help care for patients through secure electronic messaging. To encourage this, providers were given a minimal financial incentive beyond their salary for each message thread that is, an inquiry from patients followed by a response from a provider, or vice versa. 24 Providers were expected to answer all secure messages from patients by the end of the next business day. Patients and providers were otherwise free to incorporate secure messaging into care as they saw fit. All normal laboratory test results were visible to patients at the same time they became available to physicians. Most abnormal test results were visible to patients a day later. A full description of the patient Web site s time line and integration with clinical care is available elsewhere. 18 Study Data And Methods To describe patterns of use of online services linked to the electronic health record over time, we performed a retrospective, serial, crosssectional study of the adoption and use of the patient Web site from 1 September 2002 through 31 December We measured access to the patient Web site by tracking the cumulative monthly registrations by patients. To examine use of individual online services, we calculated the number of unique users in each month divided by the total number of adults registered to use the services during that month. To compare use of secure messaging to other forms of care, we measured total outpatient enrollee encounters, which included the sum of all in-person, phone, and secure messaging visits between patients and providers. The study population included all patients who received primary care at Group Health s twentysix clinics. Monthly registration activity for the patient Web site was limited to the twenty-two Group Health clinics in western Washington for which data were available. Study Results By 31 December 2009, 58 percent of the adult enrollee population was registered for access to the online services described above (Exhibit 1). Cumulative increases in registration for access to these online services did not have a visible plateau. At the end of the study in December 2009, unique monthly users per 1,000 adult members used the online services in the following ways (from highest to lowest) (Exhibit 2): (1) to request medication refills (103/1,000 in December 2008, the latest data available); (2) to review medical test results (102/1,000); (3) to exchange secure electronic messages with health care providers (69/1,000); (4) to review aftervisit summaries (41/1,000); (5) to review a list of medical conditions (20/1,000); (6) to review a list of immunizations (18/1,000); (7) to schedule office appointments online with physicians (15/1,000); and (8) to review a list of allergies (5/1,000). Of all outpatient primary care encounters in August 2009, secure messaging accounted for 30.7 percent; phone visits, 15.3 percent; and in-person visits, 54.0 percent. Discussion In this study, the online services of the electronic health record were a regular part of care for the majority of Group Health patients. Just under a third of all outpatient primary care visits with patients were through secure electronic messaging with providers. In addition to secure messaging, the other most commonly used services were online medical test results and after-visit summaries, and electronic ordering of medication refills. These four services also showed the greatest growth in use over the study period. These results complement prior studies of patient satisfaction and use of online electronic health record services at Group Health. In a 2004 survey of a random sample of Group Health APRIL :4 HEALTH AFFAIRS 609

4 EXHIBIT 1 Patients Access To Shared Electronic Record On The Group Health Cooperative Patient Web Site, September 2002 December 2009 Percent of adult members enrolled SOURCE Authors analysis of Group Health automated Web-site usage data. patients who had used the secure patient Web site, 94 percent were satisfied or very satisfied. Notably, patients said that they were most satisfied with services directly linked to the electronic health record, such as getting medication refills, viewing test results, and secure electronic messaging. Internal surveys at Group Health also suggested that online services strongly influenced many enrollees choice to stay with care at Group Health. 25 Consistent with the aim of the shared record to support ongoing collaboration between patients and providers, studies at Group Health and elsewhere have found that online services linked to the electronic health record were most used by patients with serious chronic health care needs, including those with depression, HIV, and diabetes. 17,18,26,27 At Group Health, studies have shown that providers level of secure messaging services heavily influenced whether patients used the online messaging and other online services of the electronic health record. Patients were more likely to use the online services of the electronic health record if they had a primary care provider or switched to one who was in the habit of using secure messaging to communicate with patients. 26,27 This may have been due, in part, to timely response by providers. Indeed, 97 percent of all patient messages were answered by the end of the next business day. 28 Results of the current and past studies suggest that most patient engagement with the electronic health record is not focused on viewing EXHIBIT 2 Use Of Shared Electronic Record Services On The Group Health Cooperative Patient Web Site, December 2002 December 2009 SOURCE Authors analysis of Group Health automated Web-site usage data. 610 HEALTH AFFAIRS APRIL :4

5 Patients positive experiences with online services informed Group Health s effortto create the patientcentered medical home. an archive of past care, but rather on actively using a constellation of services that support day-to-day care needs and patient-provider relationships. Broader Redesign Of Care The rise in patients use of online electronic health record services bridged two major redesigns of care at Group Health over six years. Measurement of patients experiences was critical to evaluating these efforts and using the results to assess and improve care. In the first redesign effort, beginning in 2002, assessing and increasing patients engagement with the electronic health record was part of a broader approach to improving access to care. 19 For those patients who were unable or preferred not to use online access, phone visits and in-person visits were available. Additionally, after-visit summaries were given in print form during in-person visits and provided in the shared electronic record. Medication refills were available over the phone or online, while medical test results were available by mail and online. In a prior study of this access redesign, patients reported getting care more quickly and easily, and having an easier time connecting with their personal doctor when needed. 29 These results, combined with satisfaction results from a biennial survey of patients use of online electronic health record services, provided feedback to support an interconnected system of online, phone, and in-person care designed to meet the needs and preferences of individual patients. Patient-Centered Medical Home Patients positive experiences with online services also informed Group Health s second redesign effort, in 2006, to create the patient-centered medical home. Rapid adoption of online services presented a good opportunity to engage patients further in more comprehensive care outside of office visits over the patient Web site. Alongside the benefits for patients, however, a study of primary care providers found that earlier redesign efforts were accompanied by increased fatigue in the primary care workforce and reductions in the quality of their work life. Simultaneous expectations for high in-person productivity, larger panels of patients, and growing numbers of secure messaging and phone contacts led to long hours and concerns about burnout. 21 These results were echoed by studies outside of Group Health showing that providers were concerned about the excess workload and lack of reimbursement associated with exchanging secure electronic messages with patients. Begun in 2006 as a pilot, the patient-centered medical home sought to improve patients experiences, improve providers quality of life at work, and reduce overall health care costs. Group Health reassigned patients to reduce the number of patients whom a primary care physician oversaw. Team roles were reorganized to accommodate the needs of patients, particularly those with complex and challenging chronic health conditions. Secure messaging and phone visits were further emphasized in regular care as well as in previsit planning. The goals were to clarify visit expectations and complete other tasks as well as to conduct post-visit follow-up. In a prior study of this medical home pilot, providers reported less emotional exhaustion and a stronger sense of personal accomplishment, while patients reported better experiences with care across most indicators. 22 Cost Effects Despite the primary care staffing investments, research showed that costs were recouped in the first year largely as a result of reductions in emergency room use. 22 Based on the initial success of this pilot, Group Health began spreading the medical home redesign to all twenty-six clinics in Providing strong support for providers to communicate with patients outside of office visits was considered essential to the success of the medical home pilot. Policy Implications Several conclusions can be drawn from the Group Health experience, as follows. Patients Experiences Patients experiences with care incorporating electronic health records need to be measured as part of meaningful-use criteria. Although the current criteria appropriately target measurement of several clinical quality outcomes, they include no measures of patients experiences with electronic health records. Gauging the patient experience, APRIL :4 HEALTH AFFAIRS 611

6 however, is essential to improving the quality of health care. 30 One problem is that policy makers are hesitant to require measurement that relies on survey data, for fear of placing an undue burden on practices. Indeed, surveying patients on care experiences is more costly than retrieving the currently proposed measures, which are based on automated data. But if poorly implemented, online access to medical records and patientprovider messaging may lead to patient disappointment and threaten patient-provider relationships. 16,31 For example, an implementation of Google Health that pulled a list of medical conditions based on billing codes directly from the electronic health record was recently halted as a result of patients frustration with inaccuracies in the records. 32 In studies from other settings, patients expressed concern that providing electronic messaging with physicians could undermine relationships if it detracted from physicians availability by phone or in person. 16 Evaluating patients experiences with care that includes direct engagement with the electronic health record would help ensure the quality of those experiences and alignment with other quality programs. As a start, the Agency for Healthcare Research and Quality (AHRQ) is currently testing an expanded version of the Consumer Assessment of Healthcare Providers and Systems, a commonly used survey measure of patients experiences with care. The expanded version of the tool includes assessment of patients engagement with online services linked to electronic health records. AHRQ is also reviewing this measure to ensure that the survey captures the important elements of a patientcentered medical home. Integrating such a tool into the meaningfuluse measures would help to keep the focus of redesign efforts squarely where it should be: on the patient. Payment Policies Reimbursement needs to support patient-centered access that includes phone contact and secure electronic messaging. For successful engagement of patients and families with electronic health records, reimbursement reforms are needed. These should support patients ability to get the right care at the right time, whether over the phone, in person, or through electronic messaging. The dominant reimbursement model in ambulatory care focuses on the outpatient visit. Group Health s experience highlights the importance of giving patients and providers the freedom to communicate to meet patients needs, whether in person, over the phone, or online Reimbursement models need to recognize the interconnected nature of different ways providers and patients communicate. through secure messaging. Reimbursement models need to recognize and promote the interconnected nature of different ways providers and patients communicate to support the provision of care. Providers with bundled payments for one population and unbundled payments for another population face major barriers to improvements in the effectiveness and efficiency of access. For broad-based success, providers will need alignment of payment models at the national level to support all modes of access, rather than the currently fragmented payment system involving multiple plans across multiple insurers. Conclusion Electronic health records that directly engage patients and families represent a platform for improving access to care, empowering patients, and supporting care between office visits. Group Health s investment in its shared electronic health record began more than six years ago. The process of understanding and optimizing the functions of that system have required ongoing evaluation and practice redesign. For these lessons to be transferred to other electronic health record implementations, policy makers and organizations should first ensure that patients have appropriate and preferred access to care when and where it is needed. In addition to the currently proposed measures of clinical quality, meaningful-use measures for electronic health records should include assessment of patients experiences across all of these forms of care.with the right incentives and measures in place, engaging patients through electronic health records will provide an outstanding foundation for improving the health and health care of patients. 612 HEALTH AFFAIRS APRIL :4

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