IN ENGAGING PATIENTS THE ROLE OF HEALTH IT PREPARING FOR ACCOUNTABLE CARE:

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1 PREPARING FOR ACCOUNTABLE CARE: THE ROLE OF HEALTH IT IN ENGAGING PATIENTS Authors: Caitlin Lorincz and Erica Drazen The ACA of 2010 includes numerous provisions that tie reimbursement to performance, emphasize the need for the provision of high-quality, patient-centered care and necessitate better patient engagement activities: Value-Based Purchasing Program Beginning in October 2012 (FY 2013), CMS will provide hospitals that meet established performance or improvement standards with value-based incentive payments. Excessive Hospital Readmissions Penalty Beginning in October 2012 (FY 2013), CMS will reduce reimbursement for hospitals with excess readmissions for pneumonia, heart failure and acute myocardial infarction. Additional conditions will be added starting in 2014 (FY 2015). Shared Savings Program Groups of providers will be able to establish Accountable Care Organizations (ACOs) by January 2012 for the care of Medicare fee-for-service beneficiaries. ACOs that satisfy quality performance requirements and reduce their costs will be given a share of the savings. Introduction While the concept of accountable care has existed for some time, the Patient Protection and Affordable Care Act (ACA) of 2010 lends it greater prominence. Going forward, patient care is expected to become more patient-centered and proactive with an emphasis on keeping patients healthy. The hope is that such means will improve quality and patient outcomes, while also helping to constrain costs. As healthcare organizations become more accountable for the care that they provide, engaging patients in their health and wellness will become increasingly important. Office visits are short and periodic at best. Patients already provide much of their care themselves on a day-to-day basis, either directly or with the assistance of family members. The better engaged and informed that patients are, the better able they will be to make sound care decisions and keep themselves healthy. Recently, the notion of accountable care has largely been discussed in the context of Accountable Care Organizations (ACOs) and the Medicare Shared Saving Program. Established under the ACA of 2010, the program allows providers to form ACOs and assume responsibility for the care of Medicare beneficiaries. ACOs that are able to effectively coordinate patient care, satisfy quality performance requirements and reduce their costs will be given a share of the savings. However, healthcare organizations would do well to remember that the ACA includes several provisions besides the Shared Savings Program that will also hold providers responsible for the care that they provide, including several programs that tie reimbursement to performance and emphasize the need for the provision of high-quality and patient-centered care. For instance, beginning in October 2012 (FY 2013), the Centers for Medicare and Medicaid Services (CMS) will provide hospitals that meet established performance or improvement standards with incentive payments under the Value-Based Purchasing program. 1 In the first year, providers will be assessed on both clinical process of care measures, as well as patient experience measures, such as the extent to which patients perceived that doctors and nurses listened and explained things to them. Beginning in 2013 (FY 2014), the program will incorporate outcome and efficiency measures, including 30-day mortality rates for acute myocardial infarction, heart failure and pneumonia, as well as Medicare per beneficiary spending. In addition, under the Hospital Readmissions Reduction Program, CMS will reduce reimbursement for hospitals with excess readmissions for pneumonia, heart failure and acute myocardial infarction beginning October 2012 (FY 2013). Additional conditions will be added starting in 2014 (FY 2015). Taken together, all of these programs set up strong incentives for healthcare organizations to monitor patients and keep them healthy and engaged. Clearly, change is afoot. While a few organizations will be concentrating on what needs to be done to form an ACO, all healthcare organizations should direct their attention more broadly and prepare to deliver accountable care: high-quality care that improves outcomes for patients, boosts population health and lowers costs. As healthcare organizations become more accountable for the care that they provide, engaging patients in their health, wellness and medical decisions will be increasingly important. However, it won t be an easy task. For healthcare

2 organizations, the challenge lies in how to successfully motivate patients to take an active role in their health and medical decisions. Given that patients have not always shown an interest in such activities in the past, it is clear that organizations will have their work cut out for them. Patient engagement will ultimately be a two-way effort enabled by key health information technologies (Health IT). Healthcare organizations need to start by reaching out to their patient populations to understand their health needs and get them involved in taking responsibility for their health. Patients will need to connect with healthcare organizations and their doctor s offices, learn to accomplish administrative tasks remotely and begin monitoring their health in collaboration with their providers. To successfully engage patients, healthcare organizations should take advantage of four dimensions of Health IT tools to: 1). Enable Patient Identification and Tracking 2). Promote Patient and Provider Interaction and Communication 3). Increase Patients Access to Personal Information and Self-Service Capabilities 4). Encourage and Support Patient Self-Care Activities Effective use of these Health IT tools will be essential to engaging patients. Each of these tools holds value individually and in concert with the rest. Healthcare organizations will need to prioritize their adoption and implementation of tools based on their available resources and needs. Health IT Tools to Enable Patient Identification and Tracking: Electronic Health Records Patient Registries 1). Health IT Tools to Enable Patient Identification and Tracking In seeking to engage patients, healthcare organizations first need to identify and study their patient population to understand their conditions, healthcare needs and resource usage. In addition, providers need a mechanism to track patients overtime and identify patients who could benefit from more targeted outreach. Electronic health records and patient registries can assist providers in these ongoing efforts. Electronic Health Records (EHRs) EHRs, if available, can assist healthcare organizations in evaluating their patientbase. EHRs generally provide a longitudinal account of a patient s history and contain information on medical conditions, vital signs, medications, immunizations, laboratory tests, radiology reports and other relevant data. EHRs can provide data on individual patients, as well as aggregate data for population-based reports. Taken together, this information can help healthcare organizations better understand their patient population and aid in the coordination of patient engagement activities. Early accountable care experiments employed both EHRs and dedicated registry products. Under the Medicare Physician Group Practice (PGP) demonstration, participants such as the Billings Clinic and Geisinger Health System used their EHR systems to monitor patients and identify individuals who could benefit from extra attention. Patient Registries Patient registries can assist healthcare organizations in effectively monitoring patients over time. Registry tools, in their most basic form, provide conditionspecific lists of patients with certain health care conditions. More sophisticated versions provide detailed reports on both individual patients, as well as patient populations. Registries can also be used to identify patients who are lagging behind in recommended care and generate reminders. Registry functions are available as part of EHR systems or through a variety of dedicated registry tools. 2 Healthcare organizations without established EHRs can create patient registries based on their internal administrative information or Medicare claims data that will be provided as part of the Shared Savings Program. Early accountable care experiments employed both EHRs and dedicated registry products. 3 Under the Medicare Physician Group Practice (PGP) demonstration, participants, such as the Billings Clinic and Geisinger Health System, used their EHR systems to monitor patients and identify individuals who could benefit from extra attention. Among other features, the EHR system aided in the construction of registries or condition-specific lists of individuals with various chronic diseases. In this manner, Geisinger tracked patients over time, determined which patients needed or had received recommended ( standard-based ) treatments, and coordinated outreach to those who had gaps in their care. St. John s Health Preparing for Accountable Care: The Role of Health IT in Engaging Patients 2

3 System in Missouri, another PGP demonstration program participant, also used registries to track patients. However, because it did not have an established EHR system, the group constructed an electronic patient registry based on Java and made it accessible through their system-wide intranet. Among other features, their registry included an Exception List that identified patients who were overdue for recommended care. Research indicates that EHRs and patient registries may help healthcare organizations optimize their use of time and outreach approaches. For instance, researchers at the Massachusetts General Physicians Organization in Boston developed and implemented a registry population manager for diabetes patients in a single practice in The results were overwhelmingly positive. Prior to deployment, two nurses allocated four hours each week to monitoring patients and could review patients an hour or roughly 200 patients a month. Once the registry was implemented, one nurse could review approximately 180 patients per hour. As a result, patient reminder notices could be generated and mailed more quickly, decreasing the time for patient monitoring and engagement from 30 days to 2 days. Health IT Tools to Promote Patient and Provider Interaction and Communication: Secure Messaging e-visit/tele-visit Social Media 2). Health IT Tools to Promote Patient and Provider Interaction and Communication Enabling interaction and establishing secure lines of communication help to build relationships and link patients to providers, which reduces the likelihood that patients will seek care elsewhere and preserves continuity of care. In addition, increased interaction allows for the sharing of timely health information. This ensures that patients are properly supported and that providers have the information they need to update health regimens and avoid potential complications. Both aspects help to keep patients healthy and costs down. Secure messaging, e-visits and social media can support such interactions. Secure Messaging Secure messaging offers a convenient and readily accessible method for keeping patients and providers connected. Through the use of secure messaging, which is often offered via internet-based patient portals, data is encrypted between parties to prevent an unauthorized third party from accessing sensitive information. Alternatively, information can be securely shared through protected s, such as Cisco s Registered Envelope Service. As patients take greater control of their self-care, secure messaging provides patients with a private forum to ask questions, seek clarification and request feedback on a variety of topics. Messaging also enables patients to initiate non-urgent requests at their convenience, even if it is outside of normal office hours. Research indicates that secure messaging can benefit both patients and providers. Findings suggest that the availability of messaging can increase communication, improve the quality and effectiveness of care, and may help patients with chronic illnesses better manage their conditions. 5,6,7,8 In addition, one study found that some patients are more comfortable asking questions or seeking clarification through messages rather than in-person communication. 9 Research has also shown that the availability of patient-provider messaging reduces office visits and telephone calls, can increase productivity and may help contain costs and free up staff time. 10,11,12 For instance, a Kaiser Permanente Northwest study found that access to messaging decreased annual office visit rates by 9.7 percent. The authors then compared the office visits and telephone contact rates among a subset of members to a matched control group without access to messaging. The results showed that both office visit and telephone rates for the intervention group were lower than for the control group by a difference of 6.7 percent and 13.7 percent, respectively. 13 e-visits/tele-visits Telemedicine provides another avenue for increased patient-provider interaction through the availability of e-visits and tele-visits, which are interactive remote consultations that can occur over the phone or via in lieu of traditional Preparing for Accountable Care: The Role of Health IT in Engaging Patients 3

4 office visits. Tele-visits, a subset of e-visits, can be facilitated through the use of interactive and secure internet-based video conferencing. Research indicates that remote consultations can provide an efficient forum for discussion of various non-urgent matters that would otherwise be discussed in an office visit, such as new symptoms, care needs, prescription renewals, laboratory test results and other routine matters. 14 Tele-visits can also be used in concert with remote monitoring devices to provide more intensive engagement and management of chronically ill patients. The Diabetes Education and Telemedicine project equipped New York-based Medicare beneficiaries with diabetes with internet-enabled computers and modem connections. Through the use of these tools, patients were able to engage in remote monitoring of their glucose levels, participate in videoconferencing with nurse case managers, connect to a portal to access their personal health information, send messages to providers and access informational resources. Results from the program showed that after 1 year the intervention improved patients blood pressure levels and glycemic control, as well as total and lowdensity lipoprotein cholesterol levels. 15 Dr. Jeff Livingston, a Texas-based obstetrician and gynecologist, uses social media to stay in touch with his patients. As of 2010, he had roughly 600 fans on Facebook and 1,500 followers on Twitter. The results have been positive: He says that his patients are better educated and come to appointments more prepared. Health IT Tools to Increase Patients Access to Personal Information and Self-Service Capabilities: Patient Portals Patient-Maintained Health Record Personal Health Records Social Media Social media presents another means for encouraging patient and provider interaction and may be an especially promising forum for educational outreach. Through blogs and social network sites, such as Facebook and Twitter, forwardthinking hospitals and physicians are sharing educational information as well as motivational messages, and general health care reminders with patients. Dr. Jeff Livingston, a Texas-based obstetrician and gynecologist, believes that social networking has had a positive impact on his patients. As of 2010, he had roughly 600 fans on Facebook and 1,500 followers on Twitter. According to Dr. Livingston, his patients are better educated and come to appointments more prepared. If you allow your patients to become engaged in their own health care, they ironically make really good decisions. I think that s a new concept for a lot of people, he said. 16 3). Health IT Tools to Increase Patients Access to Personal Information and Self-Service Capabilities Self-service technologies allow patients to view and monitor their personal medical information, accomplish administrative and financial tasks, and access educational information online from their personal computers. Ready availability of current information and timely access to providers binds patients more closely to the network and potentially decreases the likelihood that they will seek care elsewhere. 17 Patient portals and, to a lesser degree, patient-maintained health records and personal health records also have the potential to help connect patients with their personal information. Patient Portals Patient portals are internet-based tools that can provide patients with the health information necessary to involve them in their care processes. Analogous to online banking websites that enable individuals to access and interact with their financial information, provider- or payer-sponsored patient portal websites allow patients to access and interact with their healthcare information. Patient portals can allow patients to connect to an established EHR system, access personal health records, view their claims data as well as other information, such as personal care plans, test results and medication lists. Some portals offer patients personalized educational modules as well as customized reminders and alerts. Portals may also enable patients to accomplish various administrative and financial tasks, such as appointment scheduling and bill payment, and connect with providers via secure messaging options. Since portals are internet-based, patients can access their information from any computer at anytime, even during hours when their providers offices are closed. For instance, Medicare beneficiaries can log into MyMedicare.gov, a Medicarehosted interactive portal, at anytime to access personalized information, such as Preparing for Accountable Care: The Role of Health IT in Engaging Patients 4

5 Medicare beneficiaries can log into MyMedicare.gov, a Medicare-hosted interactive portal, at anytime to access personalized information, such as eligibility status, coverage information and claims data. In addition, patients can also take advantage of the new blue button feature to download their personal health information. eligibility status, coverage information and claims data. In addition, patients can also take advantage of the new blue button feature to download their personal health information. Patient portals were also used in early accountable care experiments. Geisinger Health System, a Medicare Physician Group Practice demonstration program participant, offered patients a patient portal called, MyGeisinger.org. Through this access point, patients could view their medical records, test and lab results, as well as schedule appointments, contact their providers, request prescription renewals and other tasks. Some health care systems with established patient portals are developing mobile applications that allow patients to access information from their phones. For instance, MyChart, an application developed by Epic and deployed by the University of Utah Health Care System and other sites, allows patients mobile access to their medical records. Patients can view test results, medication lists, immunization records, appointments and other information on the go. Information is kept secure behind the University s firewalls and patients must enter proper log-in information on their devices. As they mature, patient portals may borrow some of the features of social media websites. Some integrated health systems have already incorporated some social media aspects into their own internet-based tools. Kaiser Permanente and Palo Alto Medical Group, among others, already provide patients with social mediarelated features. For instance, patients using Kaiser s My Health Manager can view information on their physician(s) in a profile-like format (complete with color photos), read physician-authored blogs and send secure messages to their providers. Patient-Maintained Health Record Patient-maintained medical records are another tool that provides patients with access to their personal information. Such records allow patients to manually document their own healthcare information and combine information from various providers. Patient-maintained health records are not tethered to an external source. However, some versions allow patients to authorize certain third parties, such as providers, payers and pharmacies, to access and update their personally-maintained health record. In addition, some versions allow patients to customize their records by adding various third-party solutions, such as medication management tools or tools that relate to specific medical conditions. Various vendors offer internet-based, patient-maintained health record tools, such as Microsoft HealthVault. Medicare is experimenting with equipping beneficiaries with access to patientmaintained health records populated with claims information. CMS refers to these tools as personal health records, but given that they do not provide comprehensive patient information, they cannot be considered a true personal health record (as discussed below) and more closely resemble patient-maintained medical records. Among other activities, CMS launched the My Personal Health Record, South Carolina pilot in 2008 and the Medicare Personal Health Record Choice pilot in 2009 to provide patients with free access to internet-based PHRs. With patients permission, PHRs are populated with 2 years of claims data and can be connected to other sources, such as their local pharmacy, to receive additional data. Beneficiaries can also customize their records by adding personal healthcare information. Beneficiaries participating in these pilots have control of their PHRs and decide who can view them. Both pilots run through Personal Health Records (PHRs) PHRs are tools that can potentially increase patients access to their personal medical information. In contrast to patient-maintained health records, true PHRs capture information from patients as well as providers and are comprehensive, interactive, patient-controlled and secure. 19 In particular, PHRs must be comprehensive and capable of receiving complete and accurate patient information from all settings where patients received care. In addition, PHRs must also be interactive and allow patients the ability to update their records and receive feedback from providers. They should fundamentally be patient- Preparing for Accountable Care: The Role of Health IT in Engaging Patients 5

6 controlled; with patients having lifetime access to their PHRs and the ability to oversee who is able to access their information. Lastly, all of the information should be kept secure and accessible only to patient-authorized third parties. Existing PHRs suffer from various limitations. None of the existing options can be considered a true PHR and thus far, patient utilization of PHRs has been low. More work needs to be done to establish processes for incorporating patientgenerated data into PHRs. Going forward, as shortcomings are addressed, PHRs may become a more useful patient self-service option. Findings show that self-service tools, such as patient portals, can positively affect patient and provider communication and disease management activities. 20 While limited, research has also shown that providing patients with access to their medical information can increase their knowledge and provide a greater sense of control over their health care. 21,22 When such information is available electronically, it can prompt individuals to take a more active interest in their healthcare. For example, in a 2010 national survey, only 7 percent of respondents (n=266) indicated having used a PHR. However, among those who did, more than half indicated that the ability to review their health information online has made them feel more knowledgeable about their own health (56 percent) and better able to understand the health care treatments prescribed by their doctors (52 percent). In addition, roughly one-third of respondents indicated that this has prompted them to take steps to improve their health (32 percent) and made it easier to discuss their health condition(s) with family members (31 percent). 23 Health IT Tools to Encourage and Support Patient Self-Care Activities: Telemedicine/Tele-Monitoring Mobile Health Applications 4). Health IT Tools to Encourage and Support Patient Self-Care Activities Patient self-care technologies can assist patients in their wellness activities and disease-monitoring tasks by collecting and tracking relevant patient health data overtime. Telemedicine and mobile health provide two promising examples of patient self-care technologies. Telemedicine/Tele-Monitoring While different definitions exist, telemedicine can be considered the provision of healthcare services, through the use of information and communication technologies, in situations where the health professional and the patient (or two health professionals) are not in the same location. 24 In addition to e-visits and tele-visits, telemedicine can encourage the involvement of patients in self-care activities through tele-monitoring or remote health monitoring. Through the use of wireless-enabled remote monitoring devices, which are used by patients at directed frequencies, health data is collected and routed to a computer in patients homes. From there, patients can review their stats and transmit the information to their providers through the use of an internet or direct patient portal connection. A variety of remote health-monitoring devices exist, including stand-alone options, as well as some that can be integrated with other technologies. Some examples include weight scales, blood glucometers and blood pressure cuffs, stethoscopes, and many others. Tele-monitoring can benefit both patients and providers. By capturing relevant health data, remote monitoring can help patients with their wellness and disease management self-care activities. In addition, by transmitting data to providers, it can ensure that providers have the information necessary to effectively support patients changing needs in between office visits. Timely review of patient data allows providers to stay abreast of developments and actively react if potential complications are detected. By staying abreast of patient status in this way, providers can move away from an event based approach in which they react to exacerbations of illness and toward active prevention. 25 Tele-monitoring technologies can be deployed in a variety of ways. An innovative cloud-based telemedicine platform called emedlink has been used to target patients who are at greatest risk for re-hospitalization. Prior to discharge, hospitalized patients are invited to participate in the program and educated in how to use the technology. Patients are then equipped with a unit consisting of Preparing for Accountable Care: The Role of Health IT in Engaging Patients 6

7 An innovative cloud-based telemedicine platform called emedlink allows patients with chronic conditions to be closely monitored at home. Patients are equipped with a unit consisting of a computer-based patient terminal configured for their specific clinical condition and drivers to enable connection with measuring devices. Patients take health data at specific times, which is collected through the measuring devices and communicated to the patients terminals via a Bluetooth or USB connection. Data is transmitted and available for patient and provider review in real-time; patients receive instantaneous feedback on their conditions and providers are alerted to potential problems. a computer-based patient terminal configured for their specific clinical conditions and drivers to enable connection with measuring devices. Patients agree to take necessary health data at specific intervals as instructed by their providers. Clinical data is collected through the measuring devices and communicated to the patients terminals via a Bluetooth or USB connection. Once captured, the data is securely transmitted to the care team s terminals and can then be stored within the emedlink solutions database or integrated into the electronic patient records. Data is transmitted and available for patient and provider review in realtime; patients receive instantaneous feedback on their conditions and providers are alerted to potential problems. The platform also offers both voice and n-way remote video consultations and allows patients to interact with one or more providers as needed from anywhere in the world. 26 While the body of research on remote health monitoring is limited, some studies show promising results. Research indicates that, among other benefits, it can empower patients and impact their behaviors. 27 Some research also shows that it can positively affect patients health and may be an effective method of treating patients with chronic conditions. 28,29,30,31,32,33 In addition, remote monitoring may help reduce hospital admissions and length of stay and could reduce health care expenditures over time. 34,35 For instance, the Veteran s Health Administration established a national tele-health program, Care Coordination/Home Telehealth (CCHT), between July 2003 and December The program coordinates in-home services for veteran patients with chronic care needs and in addition to leveraging the use of telemedicine and disease-monitoring technologies, the program encourages patients to engage in self-management activities. As of 2008, a total of 43,430 patients had participated in the program since its inception. In examining a cohort of 17,025 CCHT patients, researchers report that the program reduced hospital admissions by roughly 20 percent and lowered hospital length of stays (bed days) by more than 25 percent. Further, with an average cost of $1600 per patient each year, the authors assert that the program is a cost-effective option for care in face of other, more costly care options, such as home-based primary care services ($13,121/year) or nursing home care ($77,745/year). 36 Mobile Health (mhealth) Smartphones equipped with mobile health (mhealth) applications are also useful self-care tools and provide another method that healthcare organizations can employ to engage patients. Smartphones harness the power of a computer into an inexpensive hand-held device. Mobile health applications can assist patients in self-care activities by allowing them to track their health information in the palms of their hands. As of December 2009, roughly 42 percent of Americans owned smartphones. 37 Applications that are tied to smartphones are especially useful in supporting patients care needs because many patients are rarely without their phones throughout the course of a given day. An ever-increasing number of applications that operate from internet-enabled smartphones, such as Androids, Blackberrys and iphones, can assist patients in providing self-care. Existing applications focus on a variety of health topics, including medication management, chronic disease control, wellness activities and others, but vary in style and complexity. Such applications feed information directly to patients phone and can provide general or customized content, push messages, such as pre-set medication reminders, health data capture, and other interactive services. For instance, applications such as PillBox help patients improve medication adherence by generating reminders for patients to take their medication. 38 Other applications, such as itriage, can assist patients when they are ill by providing information on their symptoms and use GPS technology to locate their nearest provider. 39 Both applications can be downloaded for free from the itunes store. Little information is presently available regarding these applications effectiveness or impact on patient behavior. However, as better research becomes available, healthcare organizations may wish to distribute information on successful applications to their patients, especially those which can be downloaded for free. Preparing for Accountable Care: The Role of Health IT in Engaging Patients 7

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