Tuesday, April 24, 2012

Consumer/Patient Engagement Power Team Unveils Recommendations

The Consumer/Patient Engagement Power Team is assessing the Standards and Certification Criteria NPRM and providing recommendations for strengthening consumer/patient engagement components. The Power Team has prioritized recommendations to enable patients to participate as partners in their care. These recommendations can be downloaded here, and I have embedded them below. The presentation to the April 18, 2012 HIT Standards Committee meeting by Leslie K. Hall was truly outstanding. Take a few minutes to listen to this presentation:

Jim Hansen, Dossia Consortium in the document "Two key EHR-related catalysts to support patient engagement and accelerated health system transformation: Effective view, download and transmit capabilities and actionable recorded patient preferences" outlined the work of this group very well. One of the areas of focus was effective EHR View, Download and Transmit (VDT) Capabilities:
Effective view, download and transmit EHR capabilities are foundational not only for patient engagement but also to support the transformational shift to a learning health and health care system. Each function (view, download and transmit) plays a complementary role in addressing the required use scenarios.
Three core principals emerged from the Power Team discussions in support of this premise:
  • Designated Proxy - The patient has the right to designate a proxy (or proxies) indicating that interactions traditionally intended for the patient are handled by the designee(s) with and/or instead of the patient herself. Thus all comments related to patients below also apply to their designee(s), if any.
  • CC:ME - Any health information that is shared with providers and/or with the patient as an information exchange, discussion item or handout should be made available electronically with discrete computable fields and/or human readable format, based on patient preferences.
  • Incorporation of Patient Generated Data – Much of the information required to inform care decisions is gathered through a variety of inefficient and ad-hoc methods which can be significantly streamlined for efficiency and effectiveness. Standards developed for surveys of patient experience of care can be used in other applications.
The FACA Template for Input on the Certification Criteria to Support MU Stage 2 Objectives and Measures
FACA Template for Input on the Certification Criteria to Support MU Stage 2 Objectives and Measures

Monday, April 16, 2012

Promoting Patient Engagement in Meaningful Use

The proposed rule for Stage 2 Meaningful Use has a strong emphasis on patient engagement. This is certainly a good thing, and I am very glad to see the focus put on this area. As the online petition urging the ONC even further strengthen these requirements says, "Nothing would result in improving the health of the population (and decrease healthcare costs) more than having greater involvement/engagement by individuals in the healthcare process." I've signed the petition, and while the best way to have an impact is to actually submit comments on regulations.gov, this is a good way to show some critical mass on the issue. However, simply saying that it's important to strengthen the Patient Engagement requirements of Stage 2 Meaningful Use does not provide any specific guidance on what the good, the bad, and the ugly is in the proposed rule. There is a great opportunity that Nate OsitDavid HarlowAdrian GropperFred Trotter, and others from the Society for Participatory Medicine have made available to provide feedback and crowd source some comments using this form.

Some of the objectives revolving around patient engagement are:
  • Use secure messaging to communicate with patients on relevant health information
  • Use Certified EHR Technology to identify patient-specific education resources and provide those resources to the patient
  • Provide patients the ability to view online, download, and transmit their health information within 4 business days of the information being available 
  • Use clinically relevant information to identify patients who should receive reminders for preventative/follow-up care
  • Provide clinical summaries for patients for each office visit
  • Record whether a patient 65 years old or older has an advance directive
While these are laudable goals and many are achievable, the devil is in the details, and some of the measures providers will need to meet for these objectives deserve some additional consideration. For example, I'm very happy to see Direct protocols for secure messaging included in Stage 2 Meaningful Use (John Moehrke has done a great job of outlining this aspect of the rule), but the requirement that a secure message was sent using the electronic messaging function of Certified EHR Technology by more than 10 percent of unique patients seen during the EHR reporting period could be difficult for some providers to reach. It is one thing to require the providers to use secure messaging themselves but how will they ensure that patients send messages? One enterprising idea I've heard is to offer to enter patients into a raffle to win an iPad for sending a message, but this really doesn't get us closer to our goals of having patients more involved in their care. Requiring providers to communicate with each other, and requiring the capability for patients to use this functionality is important, but it will be difficult for physicians to force 10 percent of their patients to send a message.

Likewise, it is very important that providers give patients the ability to view, download or transmit their own health information. But requiring that more than 10 percent of all unique patients seen by the EP during the EHR reporting period (or their authorized representatives) view, download, or transmit to a third party their health information is again going to be a challenge for many providers. Whether the patients access their data and what they do with it is beyond the providers control. Only requiring that 50 percent of the unique patients are provided that data seems weak - I believe every patient should have full access to their own medical record - and the 10 percent rule could be a real problem in some cases. I would prefer to see the requirement reworked to report the number of patients who access and transmit their data, and patients who send secure messages. This is an important indicator that like quality measures should be captured, but making the bar too high could have the unintended effect of driving providers away form the program, which will not help achieve the goals of greater patient engagement.

Dave Chase recently wrote in TechCrunch that "providers and legacy vendors are pushing back against the requirements proposed by the ONC" and "there is a major risk that the proposed requirements will be watered down based upon this feedback." This is true, and I would be sad to see less emphasis placed on patient engagement, and actually don't think it will happen. The ONC has formed a Consumer/Patient Engagement Power Team which will assess Standards and Certification Criteria NPRM and provide recommendations for strengthening consumer/patient engagement components. I feel confident that this group will find some good opportunities to keep this critical area at the forefront. But I also think there needs to be a thoughtful approach to how best to promote patient engagement without discouraging providers to participate in the program.

The proposed rule also asks for comments on whether the recording of disability status; and of gender identity and/or sexual orientation should be added. While disability status might be achievable, it would be very difficult for providers to begin asking the sexual preference of their patients. The proposed rule states:
We encourage public comment on the burden and ability of including disability status for patients as part of the data collection for this objective. We believe that the recording of disability status for certain patients can improve care coordination, and so we are considering making the recording of disability status an option for providers. We seek comment on the burden incorporating such an option would impose on EHR vendors, as well as the burden that collection of this data might impose on EPs, eligible hospitals, and CAHs. In addition, we request public comment on—(1) how to define the concept “disability status” in this context; and (2) whether the option to collect disability status for patients should be captured under the objective to record demographics, or if another objective would be more appropriate.Show citation box We also seek comment on whether, we should also include the recording of gender identity and/or sexual orientation. We encourage commenters to identify the benefits of inclusion and the applicability across providers.
According to a report from the Institute of Medicine in March 2011 collecting data on sexual orientation and gender identity through electronic health records could help address health issues among lesbian, gay, bisexual and transgender populations. The IOM report also recommended that the requirement be included for the collection of such data in objectives for meeting meaningful use rules. However, the researchers also said this more sensitive information could be difficult to obtain. No kidding... The stage 1 requirement to record demographic information, such as date of birth, sex, and race, and ethnicity as structured data for more than 50% of patients seen has been sometimes challenging already. The capture of ethnicity was a new concept for many providers and there were many questions of clinical relevance, but the reason to capture this data was to identify disparities. Now the threshold for recording demographic data goes up to more than 80% of patients in stage 2 and adding in additional components to identify disparities would make this a very high bar.

Asish Jha, MD wrote in the Health Affairs blog that "federal policymakers are trying to move the provider community from the ‘ability’ to do things electronically to actually demonstrating that they are doing it. While this is a laudable move, I suspect that many providers are going to push back. It is not clear that 10 percent of patients will want to view, download or transmit their data to others. It is hard to imagine that we are going to punish providers when their patients choose not to look at their own data." So where does this leave us with strengthening the patient engagement components of meaningful use? I think we should just go for it: Every patient should have electronic access to their health data. Instead of only 50 percent having their data available let's acknowledge that patient's have the right to their own health data and then require providers to monitor and report on patient access. And I urge everyone involved in healthcare to sign the ONC's Consumer Pledge. It is time to give patient's their damn data! What other ways do you think we can  strengthen patient engagement in meaningful use?

Wednesday, April 4, 2012

Microsoft and Los Angeles Launch Exergamers Wellness Club

Microsoft, the City of Los Angeles Department of Aging, Partners in Care Foundation and St. Barnabas Senior Services have launched an innovative program called the Exergamers Wellness Club, which combines technology with exercise, overall health monitoring and evidence-based health education from Partners in Care. The partnership plans to extend its program to a total of 16 senior centers in Los Angeles. Seniors in the program use Kinect for Xbox 360 to make exercise fun and to supplement other fitness activities such as tai chi. They use Microsoft HealthVault to manage and store their personal health information.

<a href='http://video.uk.msn.com/?mkt=en-gb&vid=7a0ce2b5-8d4b-4519-97e1-dbe08c003ef6&from=&src=v5:embed::' target='_new' title='Ellen Kampel - Microsoft Next 2012' >Video: Ellen Kampel - Microsoft Next 2012</a>

Seniors ages 60 to 80 erupted into dance during a surprise flash mob at the announcement and were joined by others in the crowd, including St. Barnabas CEO Rigo Saborio, a St. Barnabas cafeteria worker and a Microsoft marketing manager.

Los Angeles Mayor Antonio Villaraigosa said, "The Exergamers Wellness Club allows seniors to improve their physical, mental and social well-being by participating in friendly competition, interactive gaming and tracking their health information online. It is just one way we can give back to the people who have given our city so much."

Seniors at St. Barnabas compete in virtual bowling tournaments with contemporaries across the country. They also dance to music ranging from hip hop to disco using Kinect. With Microsoft HealthVault, seniors monitor the benefits of their increased activity and have the option to track their personal health information, such as blood pressure and blood-glucose levels. They also have the option to share their online personal health information with family members or other caregivers they trust and use it with other health and fitness programs. HealthVault contains features that help protect the seniors' personal information.

To facilitate the Los Angeles expansion of the Exergamers Wellness Club, Microsoft plans to donate a Kinect, a selection of games and a one-year Xbox LIVE Gold Membership to each of the other 15 senior centers administered by the Los Angeles Department of Aging.

Microsoft also collaborated with Get Real Consulting to develop a geriatric personal health application, which enables seniors to proactively manage their health information online. The Exergamers Wellness Club kicked off in May 2011 with 22 members. It later expanded and now serves 34 seniors between the ages of 64 and 94. Continued participation is evidence of the club's value to its members.