Stage2mu part2-ptengagementtochie-121005114900-phpapp02

Meaningful Use Stage 2 (Part 2) –
Patient Engagement, HIE and TOC

Adele Allison
National Director of Government Affairs

October 25, 2012

Stage 2 MU – Infrastructure Wave

Health IT Considerations
888.879.7302 • www.SuccessEHS.com

4 Marks of Meaningful Use

Adopt and
Use CEHRT

Move
DATA


Capture
DATA

Report
DATA

Core:
Core:
Core:
Menu:
Menu:
Core:
Clinical
eCopy
Clinical
Protect
Rx
Patient
Patient
eRx
Decision
of
Summary
Reminders
Formulary
Education
Alerts
PHI
Lists
Support
Record

Adopt and
Use CEHRT

Core:
Core:
Menu:
Core:
Core:
Core:
Rx
Smoking
DemoRx
Problem
Rx
Vitals
Rx List
Allergy
graphics
Status
Reconcile
CPOE
List
List

Capture
DATA

Core:
Menu:
Menu:
Test of
Patient
TOC
Lab
Exchange
eAccess
Summary
Results

Menu:
Menu:
Core:
Syndromic
Immun.
CQMs
Surveillance

Move
DATA

Report
DATA


Registry
Data

Core:
4 MarksClinical Meaningful Use
of
Core:
Menu:
Menu:
Core:
Core:
Core:
Protect
5 CDS
Secure

eRx and
Electronic
Patient
CPOE
Messaging
Summary
and Rx
PHI
Formulary
(Rx, Lab and
Notes
w/
Reminders
(Electronic &
Lists
(Encryption)
Radiology)
Alerts
Patients
Paper Avail.)

Adopt and
Use Core:
CEHRT
Patient
Menu:
TOC

Family
Reconcile
Smoking
DemoLab
Vitals
Health
graphics
Status
Rx
Results
History

Capture
DATA
Menu:
Core:
CQMs:

View,
Production
eSummary
Download,
Imaging
of Care
Transfer
Results
Record
Info

Menu:
Production
Production
Electronic
Production
Specialized
Cancer
Immun.
eSyndromic
Reporting
Registry
Surveillance
Reporting
(EHR Direct
Reporting
Preferred)

Move
DATA

Report
DATA


• Cultural Shift
Adopt and
Use CEHRT

Move
DATA


o Change is hard → “We’ve
always done it this way.”
o Leadership and Professionalism

Capture
• Redesign will create
DATA
temporary Chaos
• Address techno-challenged
users
o Scribes
o Focused training
o Super-users

Report
• Celebrate your success!
DATA

• Workflows must be
consistent
• 3 Data-entry Types
1. Narrative Text
2. Structured Data
3. Object-oriented, Codified Data

Adopt and
• Apply the 5-Rights
Use CEHRT
1. Right Information
2.
3.
4.
5.

Right Person Capturing
Right Data Format
Right Technology Channel
Right Time in Workflow


Capture
DATA

• Define your Use Cases
o
o
o
o

Referral Management
ED/Hospitalization Notification
Emergency – “Break-the-Glass”
New/Unknown Patient

• Use Cases → 2 Clear Goals
o ↑ Quality
Capture
o ↓ Costs

Move
DATA


DATA
• Interface vs. HIE
• Health Information
Exchange
o Sustainability Model
o Emerging Technology

• Clinical Data Reporting is
Crucial!
o Drive Reimbursement Reform
under ACA (E.g. VBM)
o Physician Compare Website

• CQMs to be electronically
Move
submitted by CY2014
DATA
• Medicare Data → PQRS
o Claims-based
o Registry-based
o EHR Direct

• Medicaid Data → Ind. State
o Process and Timelines
o Interface or HIE


Report
DATA

MU2 Health IT Implementation List
CEHRT
Extensions

CEHRT
Standard Offerings
•

CPOE

•

eRx, Rx History and Formulary
(E.g., Surescripts / RxHub)

•

Rx Database

•

Master Patient Index

•

Evidence-based Guidelines

•

Patient Administration

•

Advanced Patient Portal

•

Detailed Vitals

•

Patient Education

•

Smoking Status

•

HIE → Direct / Exchange

•

Population Health Mgmt.

•

Bidirectional Lab Interface / HIE

•

Thin-Client Operations

•

Immunization Interface / HIE

•

Data Encryption Technology

•

PACS Interface / HIE

•

Internet Enabled Technology

•

•

Structured Knowledge Base

Public Health, Cancer and/or
Specialty Registry Interface / HIE

•

Documentation Tools

•

Hosting / Emergency Backup


Plugging into the Matrix
•
•

Americans are plug into the Matrix more than ever
88% Age 18+ have a cell phone (77% of Rural Residents)
• 67% Texting → Dominates, especially with Teens
75% of all Teens text
o Teens average 60 texts per day
o Girls text more than boys at 100 / day compared to 50 / day
o Black teens text average of 80 / day
o

57% have a Laptop
• 19% have a Tablet Computer
• 19% Own and e-book Reader
52% Adult Americans use phones while watching TV
•

•


•

Who: 76% Internet Use in U.S. → Ubiquitous and
Pervasive
o
o

•

What: Internet Usage
o
o
o
o
o

•

4.7% Dial-up
63.5% Broadband
62% Social Networkers
55% Share Photos
26% Comment / Blog
15% Personal Website
12% Tweet

Elderly: 53% of Age 65+ use Internet / Email
39% have Broadband
o Only 34% of Age 75+ have Internet
o


•
•

The Matrix has impacted Patients and Health Care
61% Age 18+ get Health Information Online
o

•

88% of Caregivers look online for health info

19% Source Provider Rankings / Reviews
o
o

5% Post Them
CMS → Physician Compare www.medicare.gov/find-a-doctor/providersearch.aspx

•

18% Source Hospital Reviews
o
o

•
•

4% Post Them
CMS Hospital Compare www.hospitalcompare.hhs.gov

14% of Patient sign-up for alerts
7% have health apps on handhelds


Patient Engagement Principles
•
•

Requires real change by both Providers and Patients
2 Golden Rules of Patient Engagement

1. Patient Experience best measure of patient
engagement, and

2. Solicit Patient / Family Involvement in how the
practice should work for them.
•
•

Research → Better Experience = Better Outcome
Patient Involvement → Advisory Councils, Focus
Groups, Input = Patient-designed Care Process


Area of
Family, Friends, Both Equally
Is Patient Decision-making Affected? Yes!
Professional
Advice Sought view of diet, exercise, Patients
Fellow stress mgmt.
• 49% Influences
Accurate Diagnosis
91%
5%
2%
• 38% Affected decision about seeing a doctor
Rx Information
85%
9%
3%
• 38% Altered
Alternative Treatment way of coping with Chronic Condition / Pain
63%
24%
5%
•

Specialist Recommendation

62%

27%

6%

Hospital Recommendation

62%

27%

6%

Illness Emotional Support

30%

59%

5%

Quick Remedy for Health
Issues

41%

51%

4%


Fed. Programs & Patient Engagement
•

Behavioral Economics requires an Engaged Patient
o
o

•

•
•

Effects of social, cognitive, emotion factors on patient decision-making
E.g., Airport McDonalds Story

Transition from Episodic Care to Long-Term Healing and
Wellness
Research → Patient Engagement ↑ Quality and ↓ Costs
4 Federal Initiatives with Patient Engagement Regulations
o
o
o
o

Meaningful Use Stage 2 - 7 Measures
Accountable Care Organizations – 7 Measures
NCQA Patient-Centered Medical Home – 66 Factors
Value-based Purchasing – CAPHS


Proposed Stage 2 Core Measures

Fed. Objective
Programs & Measure
Patient Engagement
Threshold
Exclusions

No.

Implement CDS to improve on high-priority
condition:
1.5 CDS interventions for 5 or more CQMs during
entire reporting period; and
2.Enable drug-drug and drug-allergy checks for
entire reporting period.
For each office visit to patients within 24 hours,
which includes up-to-date lists of problems,
medications and Rx allergies (paper and electronic
must be avail. to pt.)

5 Rules and Rx alerting
by attestation

None

1

Implement Clinical Decision
Support and Track Compliance

2

Provide Patients with Clinical
Summaries

3

Use EHR for Patient-Specific
Education Resources

Provide patient-specific education resources to all
patients

10% (Unchanged but EP has no office visit
during EHR reporting
made Core and “if
appropriate removed) period

4

Generate Lists of Patients by
Condition

1 List with a Specific Condition for use in quality
improvement, reduction of disparities, research or
outreach

By attestation (Made
Core)

5

Use of secured messaging with
Patients

50% (Unchanged)

Send secured messages to patients seen during
reporting period

10%

1.

6

7

Patients can view online, download and transfer
Timely Electronic Access to Health
info within 4 days of being available to EP, subject to
Information
2.
EPs discretion to withhold certain info

Send Reminders to Patients


Preventative and follow-up care for all patients
based on clinically relevant info for anyone with an
OV in past 24 months

50% of all pts.,
and
10% of pts.
access

10% (↓ from 20%, all
patients and Made
Core)

EP has no office visit
period

None
EP has no office visit
period
EP has no orders /
•
creates info
required
>50% visit in county
•
with >50% with
4Mbps broadband
avail.
EP has no office visit in
previous 24 months

ACOs and Patient Engagement
• 33 Quality Performance Measures
• 7 Patient / Caregiver Experience
Measure
Getting Timely Care, Appointments and Information
How Well Your Doctors Communicate
Patients’ Rating of Doctor
Access to Specialists
Health Promotion and Education
Shared Decision-Making
Health Promotion and Education

Method of Data Submission
Survey
Survey
Survey
Survey
Survey
Survey
Survey

• Final Rule requires CMS qualified Survey Vendor by 2014
• HITPC Preliminary Stage 3 Draft (Aug → Final Recommendations expected
in Nov)

o
o
o

Patients Option to submit data online → 10% submit Medical Histories
Patient education in non-English languages
10% of Patients ability to update and correct information online


PCMH and Patient Engagement
NCQA PCMH 2011
Standard and Element

Points

•
•
•

20
4
4
2
2
2
2
4
17
3
4 o
4
5
17 o
4
3 o
4
3
3
9
6
3
18
6
6
6
20
4
4
4
3
3
2

PCMH Standard 1: Enhance Access and Continuity
Element A: Access during office hours
Element B: Access after hours
Element C: Electronic Access
Element D: Continuity
Element E: Medical Home Responsibilities
Element F: Culturally & Linguistically Appropriate Services (CLAS)
Element G: Practice Organization
PCMH Standard 2: Identify and Manage Patient Populations
Element A: Patient Information
Element B: Clinical Data
Element C: Comprehensive Health Assessment
Element D: Using Data for Population Management
PCMH Standard 3: Plan and Manage Care
Element A: Implement evidence-based guidelines
Element B: Identify High-Risk Patients
Element C: Manage Care
Element D: Management Medications

Element E: Electronic Prescribing
PCMH Standard 4: Provide Self-Care and Community Support

Element A: Self-Care Process
Element B: Referrals to Community Resources

PCMH Standard 5: Track and Coordinate Care
Element A: Test Tracking and Follow-up

Element B: Referral Tracking and Follow-up
Element C: Coordinate with Facilities / Care Transitions
PCMH Standard 6: Measure and Improve Performance

Element A: Measures of performance
Element B: Patient / Family feedback

Element C: Implements Continuous Quality Improvement
Element D: Demonstrates Continuous Quality Improvement
Element E: Performance Reporting
Element F: Report Data Externally

Number
of Factors
34
4
5
6
3
4
4
8
35
12
9
10
4
23
3
2
7
5
6
10
6
4
25
10
7
8
22
4
4
4
4
3
3

Affordable Care Act mentions Medical Home 15 Times
ACA references Patient-Centeredness 36 Times
NCQA now offers a new Distinction in Patient Experience

nt r k
tie wo
Pa e
Optional with PCMH Recognition
ct Component of Quality of Care”
re Fram
“Consumer Experience is Critical
Di tont
Uses CAHPS PCMH Survey access:
66 me
rs
Access
e acto
Information g
ga
F
n
Communication
E
Coordination of Care
Comprehensiveness

Self-Management Support and Shared Decision-Making

100

149

Must
Pass?
Yes
No
No
No
No
No
No
No
No
No
Yes
No
No
Yes
No
No
Yes
No
No
Yes
No
No
No
Yes
No
No
No

6

VBP & Patient Engagement
•
•
•
•
•
•
•
•

Hospitals subject to CMS payment adjustments based on
patient experience
Starts October 1, 2012
Evaluated / Scored on performance improvements over
baseline
Patient Experience measured by HCAHPS scores
Hospital staff undergoing patient satisfaction, customer service
and communication training
Results published on Hospital Compare website
ACA has Physician VBM program starting in 2015 based on
2013 performance
Physician Compare website now in place to show performance
metrics - first publishing (limited) in CY2013


Communication Shift
•

Patient Portals have existed since 1990
o
o

•

Patient Engagement was transactional – Financial Focus
56M accessed records through Patient Portal (Oct 2011)

Paradigm shift in the way health information disseminated

Pull Information Model
Push Information Model


Patient Portal a MUST
•
•
•

Patient Engagement requires a Willing Patient
Patient Portals → Contagious and Effective Tools
Hub of the Patient, Family, Provider and Staff Communication
o
o
o

•

Web-based
Secure communication channel with clinicians
Facilitates appointments and Rx renewal

Implementation Considerations
o
o
o
o
o
o

Incorporated on Practice or stand-alone website?
Separate license cost (3rd party product)?
Integration requirements?
Browser compatibility (E.g. Microsoft Explorer, Mozilla Firefox)
Setup, configuration and training
Patient Password management


Health Information Exchange (HIE)
What is interoperability?
Transferring of data accurately from one healthcare
venue to another.

Who has ever used an ATM?
Why is Interoperability so hard to achieve in
Healthcare?


ATM Banking vs. Healthcare
ATM
Bank to Bank

Healthcare
Nursing Home
Individual Physicians
Public Health Authorities
Labs
Pharmacies
ClinicsStudent Health Center
Hospitals Payers
Dentists
Behavioral HealthDiagnostic Center

Location
Account #
Balance
Withdraw Amount

Payer Info Patient Demographics Images
Medications
Allergies
Vitals
Discharge Summaries
Immunizations
Lab Results
Mental Health
Family History
Social History
Procedures
Consult Reports

Interoperability Challenges
Challenges causing Healthcare Interoperability to be so hard to
achieve.
Variability of Applications (standards)
Funding
Processes and Document Types
Semantics and Complex Vocabulary
Privacy and Security
Free text vs. Discrete Information / Data

HIE Success Factors
•
•

Early efforts → Some succeeded, some failed
Today → Same success factors apply

Success Factors
Shared Vision with stakeholders
Incremental Approach
o
o

Limited initial goals
Build on pilots

Uninterrupted physician workflow
Internet Technology
Strong commitment to Medical Informatics

HIE Guiding Principles

Guiding
Principles


1. Improve Patient Care
2. Increase Operational Efficiency to
lower clinic costs

Use Cases and Transport Options
Examples

HIE Options

Alerting PCP to ED Visit

Direct

Transitions of Care

Exchange/XDS

Referral Management

Custom HL7 messages

Query for Documents


Direct Example → Referral Management

Consult
Referral

Jane Doe

HISP
HISP
Arrhythmia

Dr. Smith
(Internist)


Consult
Report

Dr. Heart
(Cardiologist)

Exchange/XDS Example → Car Accident

CCD
published

Dr. Smith
(Rural Health)

HIE
HIE

CCD
Request
John Doe
CCD
Response

Emergency
Urban Center

Custom HL7
Custom HL7
Established pre-IHE Standards → Long-Established HIEs DO NOT
use IHE Industry Standards
Custom Development Required
Impacts Cost and Speed of Roll-Out
Not Meaningful Use Eligible
Typically, evaluated on Case-by-Case Basis


What is a “Transition of Care?”
•

•

Movement of patients from
one provider or setting to
another
Occurs at multiple levels
o

Within Settings



o

Primary care  Specialty care
ICU  Ward

Discharge

Between Settings




o

Referral

Hospital  Sub-acute facility
Ambulatory clinic  Senior center
Hospital  Home

Across health states




Curative care  Palliative
care/Hospice
Personal residence  Assisted living

(c) Eric A. Coleman, MD, MPH

ALF / SNF

TOC Potential Issues

ICU

Home
PCP
Specialty
Pharmacy
Case Mgr.
Care Giver

Inpatient
Medication
Reconciliation?

In-Patient
SNF

ALF

Patient
Personal
Medicine List?
Coordinated
Care Plan?


Care Plan?
Medication
Reconciliation?
Personal Medicine
List?

Outpatient

Discharge
Plan?

Patient

ER

•
•
•
•
•
•

Discharge Plan?
Medication
Reconciliation?
Personal Medicine
List?

TOC and Outcomes
•

•

Problem: 75% of PCPs → No info about a patient’s
hospitalization post-discharge = Readmissions
Ineffective Transitions → Poor Outcomes and Increased Costs
1:5 Seniors (2.6M) readmitted within 30 days of discharge
o 2011 Poor Transitions → $25-45 Billion in wasteful spending
o

•

Hospitalization Care Gaps
o
o
o
o
o
o
o
o

Discharge Rx Reconciliation
Lack of Understanding of Discharge Plan of Care
Non-compliance or Untimely Post-discharge Plan of Care
No appointments with a PCP
Logistics (E.g. Transportation)
PCP unawareness of hospitalization
Lack, delay or inadequate communication with downstream provider
Lack or inadequate communication with home care provider (includes family)


MU2 and TOC / Referrals – 3 Tasks
• 1 Core Measure / 1 Task → Rx Reconciliation during TOC - 50%
• 1 Core Measure / 2 Tasks → Summary of Care Record for
TOC/Referrals
o 50% of TOCs / Referrals
- AND o 10% electronically transmitted

• Summary of Care Record Core Hospital/CAH measure, as well
• CMS Alignment → Critical to ACO Performance Gains
o 10% Improvement in DM Measures = 1% Reduction in Costs
o Conclusion: Care Coordination focus a “Must” for sustainable ACO
performance
o 6 ACO Performance measures link to care coordination

• TOC / Referral success will rely upon HIE

MU2 and TOC / Referrals – CEHRT
Inbound TOC / Referral
CEHRT Must
•
•

Display in HumanReadable Format

•

Accept CCD, CCR and/or
CCDA

•

Incorporate Rx, Allergies
and Problems

•

Transport Vehicle: Direct

•


Receive Information

Will CEHRT help
match correct patient?

MU2 and TOC / Referrals – CEHRT
Outbound TOC / Referral
CEHRT Must
•

Create the Order

•

Create CCDA (Contains
elements for Inbound TOC
requirements)

•

Provider Directory (Standard
Not Defined in Regulation)

•
•

Send CCDA

•


Connect to HISP
Possible Receipt of
Record Confirmation

Stage 2 MU – Infrastructure Wave
Tips for Success

Health IT Considerations

5 Tips for Success – Patient Engagement
•
•

Tip 1: Measure Patient Satisfaction Pre- and Post-Project
Tip 2: Involve the Provider(s)
o
o

•

Tip 3: Address Cultural-Change Challenges
o
o
o

•

They must drive the medical responses
They are going to get mad with some survey results
“One more thing I have to do!”
“Our patients will never go online”
Creates a mutual interdependence between Providers and Patients

Tip 4: Add a “filter” and Map the Workflow
o
o

o

Make the workflow someone’s job (Think “Care Team”)
Get Providers into a routine (E.g. See patients, answer emails / flags,
cycle again)
Perhaps schedule time on the Provider’s calendar


5 Tips for Success – Patient Engagement
•

Tip 5: Promote, Promote, Promote!
o

o
o

o

o

o
o

o

Refine the Message → Faster way to get lab results, refills, etc.; No
more Phone-Tag!
Strategically place Brochures (E.g., Ck-in / Ck-out, Waiting Room)
Add information on appt. reminder cards → “Use our online
scheduling!”
Remind patients of ability to request refills online when they call for
refills
Computer in waiting room to assist patients in registering, completing
paperwork, etc.
Replace “on-hold” music with introduction to patient portal
Add-on announcements with all statements, newsletters and
ePublications
Improve organizational branding


5 Tips for Success – HIE and TOC
•

Tip 1: Define your Use Cases
o
o

•

Does it improve quality?
Does it decrease costs?

Tip 2: Involve the Stakeholders
o
o

•

Tip 3: Understand your HIE Market
o
o
o

•

Hospital
Specialty Providers
Statewide / Local Market Progress and Barriers
HISP Providers for Direct
Exchange for more advance Query / Retrieve HIE

Tip 4: Allow ample bandwidth to plan and implement
o
o

Data-Sharing Agreements, SOW
Understand related Costs


6 Health IT Tips – Your IT Vendor
• Tip 1: Meaningful Use, PQRS and Other Dashboards?
o Metrics / Analytics by Provider
o Facilitates quick numerators/denominators for MU attestation
o Clinic analytics with drill-through details

• Tip 2: Patient Portal Inherent with System?

o Should be part of Core Offering
o Avoids Additional vendor and integration considerations

• Tip 3: Single database solution for PM and EHR
• Tip 4: EHR Direct PQRS
• Tip 5: More than just first call support
o Initiative Toolkits (E.g. MU, PCMH, PQRS)
o Consulting Support with domain experts

• Tip 6: Ongoing Client Educational Offerings

Added to
The BRIEF or Questions:
adelea@successehs.com
Follow me on Twitter:
www.twitter.com/Adele_Allison


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