1.
The Meaningful Care Organization –
Developing Patient Engagement Strategies
to Weather the Perfect Storm of 2013
Timothy Kelly, MS, MBA
Dialog Medical
A Standard Register Healthcare Company
2013 TxHIMA Annual Meeting & Convention
Omni Fort Worth Hotel
June 28-30, 2013

2.
2013 – A “Perfect Storm”
Four Converging Legislative Initiatives

3.
Cash for Clunkers
and Meaningful Use
Cash for Clunkers
<$3 billion
Grassley seeks accounting of 'Cash for
Clunkers' costs. The Washington Post.
January 7, 2010.
Rock and a hard place: An analysis of the $36
billion impact from health IT stimulus funding.
Price Waterhouse Coopers. April 2009.
“Meaningful Use”
(Healthcare Information Technology)
~$36 billion

4.
American Recovery and Reinvestment Act of
2009
HITECH Act
Meaningful Use
Meaningful Use (MU)
HITECH Act

5.
HITECH Act
“The changes we’re
announcing today
will lead to more
coordination of
patient care…and
greater patient
engagement in their
own care”
Health and Human Services Secretary Kathleen Sebelius
announcing the Stage 2 Final Rule. August 23, 2012.

6.
 $12.6 billion in incentives paid
to date (program inception
through February 2013)
 85% of eligible hospitals are
participating in the EHR
Incentive Program
 75% of eligible hospitals have
received an incentive payment
to date
HITECH Act
Source: CMS Fact Sheet: A Record of Progress on Health Information
Technology. CMS Media Relations. April 23, 2013.

7.
Accountable Care Organizations
Patient Protection and Affordable Care Act of
2010
Medicare Shared Savings Program
Accountable Care Organizations
Accountable Care Organizations (ACOs)

8.
Accountable Care Organizations
Voluntary groups of physicians, hospitals and other
healthcare providers:
 Responsible for care of a clearly defined Medicare
population
 Designed to foster patient-centered, coordinated care
 If it succeeds in providing high-quality care while
reducing cost, it shares in savings achieved for
Medicare
Accountable Care Organizations (ACOs)
Source: Berwick DM. N Engl J Med 2011;365:1753-1756.

9.
Three Goals of ACOs
 Better care for individuals
 Better health for
populations
 Slower growth in costs
through improvements in
care
Berwick DM. N Engl J Med 2011;364(16):e32.
Accountable Care Organizations

10.
Accountable Care Organizations
Accountable Care Organizations (ACOs)
Source: January 2012 survey of hospitals, physician organizations and health
systems reported in: Tocknell MD. The Unsettled State of the ACO.
HealthLeaders Media Intelligence Report. April 2012.
Currently part of an
ACO?
11%
No - 89%
Plan to implement or join and
ACO?
Yes - 61%
No - 39%
Yes -

11.
 Over 250 ACOs
 106 on January 1, 20131
 1 in 10 Americans is covered under
an ACO2
 Federal savings from this initiative
could be up to $940 million over four
years.1
 Top Driver for creating an ACO – To
engage physicians
 56 percent of the respondents that
are or plan to be part of an ACO3
2
HHS News Release. January 10, 2013.
1
Gandhi N, Weil R. The ACO Surprise. New York: Oliver Wyman, November 2012.
3Tocknell MD. The Unsettled State of the ACO. HealthLeaders Media Intelligence Report. April 2012.
Accountable Care Organizations

12.
 National average readmission
rate (Medicare patients): 19%
 Cost to Medicare is
$17.5 billion annually
 2,217 hospitals will face
penalties of over $280 million
in 2013
Hospital Readmissions
Reduction Program
Source: Rau J, Kaiser Health News, October 12, 2012
www.kaiserhealthnews.org/Stories/2012/August/13/medicare-hospitals-readmissions-penalties.aspx

13.
Goals of Hospital VBP Program:
 Improve patient experience
 Better clinical outcomes
1 percent Medicare Holdback
 $ 850 million in 2013
Hospital Value-Based
Purchasing (VBP) Program
Hospital Value-Based Purchasing Program Fact Sheet.
Department of Health and Human Services. ICN 907664
November 2011.
Patient
Satisfaction (30%)
Core Measures (70%)
VBP Performance
Score
+

14.
Patient-Centered
Communications
H
I
T
E
C
H
A
C
O
s
Hospital
VBP Program
Readmissions
Reduction Program

15.
Meaningful Use Objectives

16.
Stages of Meaningful Use

17.
Stages of Meaningful Use

18.
Meaningful Use Objectives
Stage 1 Objectives for Hospitals
 14 Core Objectives, 10 Menu Objectives (attain 5)
 First eligible payment year: 2011
Stage 2 Objectives for Hospitals
 16 Core Objectives, 6 Menu Objectives (attain 3)
 First eligible payment year: 2014
 Effectively incorporate all of the Stage 1 objectives,
along with additional objectives and higher
measurement thresholds
Meaningful Use Objectives

19.
Meaningful Use Objectives
Stage 2 Meaningful Use Objectives
19
Core Objectives
Demographics
Vital Signs
Clinical Decision Support
CPOE
Transitions of Care
View, Download and
Transmit to Third Party
Privacy and Security
Smoking Status
Lab Results into EHR
Patient-Specific Education
Medication Reconciliation
Patient
Input
Output
Input
Output
Input
Core Objectives
Generate Patient Lists
Immunization Registries
Lab Results to Public
Health Agencies
Syndromic Surveillance
Menu Objectives
Imaging Results
Advance Directives
ePrescribing
Electronic Notes
Electronic Lab Results
Family Health History
Patient
Input
Input

20.
Why Focus on Patient-Centered
Strategies that are “Output” or
Communication-Oriented”?

21.
“The single biggest problem in
communication is the illusion
that it has taken place.”
George Bernard Shaw
Output/Communication-
Oriented Strategies

22.
For the first time in 2012
Consumer Reports
rated hospitals.
Output/Communication-
Oriented Strategies

23.
Communication was
consistently the most
poorly rated category.
Output/Communication-
Oriented Strategies

24.
Output/Communication-
Oriented Strategies
 These metrics
are moving
beyond the
government
sites to
mainstream,
consumer sites
Patient
Satisfaction
Source: Kelly T. HIStalk, August
8, 2012
http://histalk2.com/2012/08/08/re
aders-write-8812/ (Accessed
5/10/13)

25.
“Output-Oriented” Meaningful Use
Objectives

26.
“Output-Oriented” MU Objectives
Patient-Specific Education
Patients who are provided patient-
specific education resources
Number of unique patients admitted to
the hospital’s inpatient or emergency
departments during the reporting period
> 10%

27.
“Output-Oriented” MU Objectives
 2 Measures for this Meaningful Use objective
 Both must be satisfied in order to meet the objective
View, Download and Transmit to Third Party

28.
“Output-Oriented” MU Objectives
Patients whose information is available
online within 36 hours of discharge
Number of unique patients discharged
from the hospital’s inpatient or emergency
department during the reporting period
Patients who view, download or transmit to a
third party the information provided online
Number of unique patients discharged
from the hospital’s inpatient or emergency
department during the reporting period
> 50%
> 5%*
View, Download and Transmit to Third Party
*This measure was 10% in the Proposed Stage 2 Rule

29.
Best Practices for Patient-Specific
Education Materials

30.
Best Practices
The informed consent discussion conducted by the surgeon should
include:
1. The nature of the illness and the natural consequences of no
treatment.
2. The nature of the proposed operation, including the estimated
risks of mortality and morbidity.
3. The more common known complications, which should be
described and discussed. The patient should understand the
risks as well as the benefits of the proposed operation. The
discussion should include a description of what to expect during
the hospitalization and post hospital convalescence.
4. Alternative forms of treatment, including nonoperative
techniques.
American College of Surgeons
American College of Surgeons Statements on Principles. Revised September 18, 2008.
http://www.facs.org/fellows_info/statements/stonprin.html#anchor171960 (Accessed 5/10/13.)

31.
Best Practices
 Only 39% of 3,269 closed claims against
anesthesiologists were judged to have
adequate informed consent1
 Inadequate informed consent was pursued as
a secondary cause in more than 90% of
ophthalmologic malpractice cases2
 Lack of informed consent is one of the top 10
reasons for hospital malpractice claims3
Argument for Informed Consent
1Caplan RA, Posner KL. ASA Newsletter 1995;59(6):9-12.
2Kiss CG, Richter-Mueksch S, Stifter E, et at. Arch Ophthalmol 2004;122:94-98.
3Glabman M. Trustee 2004;57(2):12-16.

32.
Best Practices
 Needs to be
electronic
 Can’t be a
“Medical Miranda
Warning”
Argument for
Informed Consent

33.
Best Practices
WHO Surgical Safety Checklist

34.
Best Practices
 Need the consent for the
Pre-Procedure
Verification and/or the
Time-Out
 Verification of the
consent is one of the
most effective practices
for avoiding wrong-
patient/wrong-procedure/
wrong-site surgery1
Argument for
Informed Consent
1Clarke JR, Johnston J, Finley ED. Ann
Surg 2007;246:395-405.

35.
Best Practices
Argument for
Informed Consent

36.
Best Practices
 Reduce the risk
of potentially
life-threatening
perioperative
complications.
Pre-Procedure Instructions
Courtesy of the Baltimore VA Medical Center
Tea C. Perioperative concepts
and nursing management. In:
Smeltzer SC, et al, eds.
Brunner and Suddarth’s
Textbook of Medical-Surgical
Nursing. Philadelphia, PA:
Wolters Kluwer
Health/Lippincott Williams &
Wilkins; 2010:422-483.

37.
Best Practices
 Lower the incidence of
preventable surgery
cancellations.
Pre-Procedure Instructions
Henderson BA et al. Incidence and causes
of ocular surgery cancellations in an
ambulatory surgical center. J Catarct
Refract Surg. 2006;32(1):95-102
Pletta C et al. Efficiency improvement plan
through patient education on thyroid
imaging procedures. J Nucl Med.
2008;49(Supp 1):426P Courtesy of the Baltimore VAMC

38.
Best Practices for Viewing, Downloading
and Transmitting Patient Information

39.
Best Practices
 Providing
patients with
incomplete
information at
discharge can
result in patient
harm.
Discharge Instructions
Courtesy of the Portland VA Medical Center
Pennsylvania Patient
Safety Advisory. 2008.
Jun;5[2]:39-43.

40.
Best Practices
 Reduced the 14-day
readmission rate
three-fold by
employing procedure-
specific discharge
instructions (4.1 per
1,000 outpatient
procedures to 1.5 per
1,000).
Discharge Instructions
Boast P, Potts C. PS&QH.
2010;7(1):14-16.
Courtesy of the Portland VA Medical Center

41.
Best Practices
 Most valuable if
they are sent well
prior to the 36-
hour threshold
 Provided prior
to admission
 Paper as well
as electronic
Discharge Instructions

42.
Developing Initiatives in Your Own
“Meaningful Care Organization”

43.
The Meaningful Care Organization
 Making Good on ACOs’ Promise — The Final Rule for the
Medicare Shared Savings Program. N Engl J Med
2011;365(19):1753-1756. November 10, 2011.
 http://www.nejm.org/doi/pdf/10.1056/NEJMp1111671
 Meaningful Use – The Whiteboard Story – Stage 1 Final Rule
Meaningful Use Objectives and Measures Compared to Stage
2 Final Objectives and Measures... Created as a reference tool
for public use and convenience by The Advisory Board Company.
 http://www.advisory.com/~/media/Advisory-com/CampaignItems/MU-
Stage-2-White-Board-Story-Poster-2.pdf
Resources
43

44.
Stage 1 Stage 2

45.
The Meaningful Care Organization
“Meaningful Care” Checklist
45
 Is the initiative patient-centered?
 Does it reduce risk?
 Does it enhance safety?
 Does it leverage the patient?
 Can you utilize HIT (EHR or
other systems)?
 Does it support Stage 1 or
Stage 2 Meaningful Objectives?
Yes No







46.
Will a Focus on Patient-Centered
Communications Impact the Selection
of Treatments/Procedures and
Potentially the Efficiency of an ACO?

47.
Potential Impact on Efficiency?
 A series of nine reports of elective surgical procedures,
released in late 2012, found wide variations in the
treatments provided.
Dartmouth Atlas Project
Improving Patient Decision-Making: Regional Series. The Dartmouth
Atlas of Health Care.
http://www.dartmouthatlas.org/pages/decision_making_series (Accessed
5/10/13.)

48.
Potential Impact on Efficiency?
 Mastectomy rates range from 0.3 per 1,000 female
Medicare patients in the San Francisco area, to 2.3 in
Grand Forks, ND
Dartmouth Atlas Project

49.
Potential Impact on Efficiency?
 The report authors surmise that patients may not
understand their full range of options and choices may
be unduly influenced by providers and not patient
preferences.
Dartmouth Atlas Project
Improving Patient Decision-Making: Regional Series. The Dartmouth
Atlas of Health Care.
http://www.dartmouthatlas.org/pages/decision_making_series (Accessed
5/10/13.)

50.
Will a Focus on Patient-Centered
Communications Impact Readmissions
or Patient Satisfaction?

51.
Potential Impact on
Readmissions/Satisfaction?
 Press Ganey analysis of hospital readmission penalty
scores vs. patient satisfaction scores.
 Positive patient experience correlates well with low
readmission rates and high readmission rates
correlate well with poor patient experience.
Press Ganey HCAHPS Analysis
The Relationship Between HCAHPS Performance and Readmission Penalties.
Press Ganey. http://healthcare.pressganey.com/content/201211-PIReadmissions
(Accessed 5/10/13.)

52.
Potential Impact on
Readmissions/Satisfaction?
 The relationship
between patient
satisfaction and
readmissions is
not causal.
Rather it is most
likely predictive of
an environment
stratified by
patient-centered
communications.
Press Ganey HCAHPS Analysis

53.
Health Information
Technology
Patient-Centered
Communications
Greater Patient
Satisfaction
Lower Readmission
Rates
More Efficient ACOs
Patient Education
Informed Consent
Pre-Procedure Instructions
Discharge Instructions
Stage 1
Stage 2 MU Objectives
Stage 3
The Meaningful Care Organization

54.
Questions?
www.standardregister.com/healthcare
www.dialogmedical.com
www.EngagingPatient.org (slides posted here)
Robbie Beck robbie.beck@standardregister.com
Tim Kelly tkelly@dialogmedical.com