In 2010, when the first stage of the meaningful use (MU) program was announced under the Health Information Technology for Economic and Clinical Health Act (HITECH), the core goals of the federal initiative were to improve how healthcare providers use electronic health records (EHRs) to improve patient care, safety, and access.
As the program evolved over the years, patient engagement became a key point of controversy within meaningful use. The Centers for Medicare & Medicaid Services (CMS) originally included requirements such as five percent thresholds for patients accessing their health data via the patient portal, but eventually scaled back those mandates to requiring just one single patient after pushback from providers who said it’s unfair to penalize them on measures that are dependent on patient action.
Indeed, some physician practices didn’t see a whole lot of value in devoting time and resources to implementing patient portals, only to have patients not take advantage of them. But with meaningful use incentive dollars hanging over their heads, it became a necessity for many. Case in point is Knoxville-based OrthoTennessee, with 58 surgeons, more than 100 providers and 10 locations in the Eastern part of the state, including its own surgery center, and which has some 230,000 patient visits per year, but would never have gone down the patient portal path if not for MU, says Karen Clark, CIO of the organization. “We were very much focused on meeting the many MU requirements, which required tremendous workflow changes in the organization, just like I’m sure they did for everyone else. So the patient portal was a requirement, and to a certain extent we only did it because it was required. We really didn’t see a whole of value in it at first,” Clark admits.
What’s more, she notes that there is even less of a value-added benefit for an orthopedic practice. “If you fracture your wrist, we will put you in a cast and we will treat you over the next six weeks, but then you go away and may never come back unless you injure yourself again. So it’s not the same as primary care at all; there you may visit the portal all the time for test results and medication refills,” she says.
Clark also recalls that when OrthoTennessee’s vendor for the portal implemented it, there was a 99-page user manual for the patient, which after pushback, became a 10-page user manual the next year. Clark says, “I said [at the time], how long is the user manual for Amazon or Expedia? We were doing the opposite of what the [intent] was for patient engagement. Instead of engaging them in a positive way, we were actively making them really mad at us, so we said ok, if we’re going to do this, and clearly our patients want this, which we were originally wrong about—they did want us to interact with us in this way—the focus of the tool needed to be about being easy to use for the patients, not easy to use for us.”
In this sense, Clark feels that the “tragedy behind health IT” is due to so much of the technology being written according to arbitrary government specification, so it is not customized to specialties or workflows. In fact, workflow was either at the bottom of some vendors’ priority lists or not on them at all, she says. “So you had this product that was clunky and cumbersome, but there were mandates that required everyone to implement it pretty quickly with short deadlines under MU. What you were left with is less than optimal products forcing physicians to use it, and as a result they have a less than optimal taste in their mouth. This leads them to think that all technology in healthcare is junk,” says Clark, who will be chairing a HIMSS user experience health IT committee this summer.
Nonetheless, OrthoTennessee has been able to attest to meaningful use successfully in all the years of the program. And now, with physician practices steered towards MIPS (Merit-based Incentive Payment System), which combines MU and other quality reporting programs for Medicare-participating clinicians, Clark says, “We have started to collect quality measures and are doing internal reporting now, for our own purposes. And we are going to look at our data, but if all goes well, we plan to report [to MIPS] for the entire year in 2017. There is an opportunity here in year one for some incentive payments,” notes the ambitious Clark, whose organization is looking to buck the trend of most Medicare physicians waiting for future years to report a full year of data to MIPS.
A New Outlook on Patient Engagement
Back to its search for a portal, eventually, OrthoTennessee took on a search for an untethered tool, landing on a solution from Cary, N.C.-based Medfusion. The biggest requirements by far, when the search was active, was that the technology is easy to use for patients, notes Clark. “Being non-tethered makes it great, meaning you can use the app to manage everything from the phone. And you can manage health for your families, not just yourself. Their website doesn’t try to boil the ocean; it does 10 things well rather than trying to do 75 things. In the time we have been using it, which has been about a year, patient complaints have dropped from a few per day to zero,” she says.
On the business side of things, it’s now much easier for patients to pay their bills directly through the tool, says Clark. In fact, in the first four to five months, OrthoTennessee’s collection on patient balances went up by a quarter of a million dollars. “That’s real. And we did zero marketing; patients found it. It’s the old notion of ‘if you build it they will come.’ We finally gave them something that was easy to use, and guess what, they used it, so we didn’t have to market it,” Clark says.
What’s more, appointment requests “shot through the roof,” as did questions to ask nurses, says Clark, adding that the cynics told her that patients would just press their providers for prescription requests through the portal, but that hasn’t happened yet. “We have gotten a few [prescription requests], but they are all legit patients trying to help themselves, so no abuse or attempted abuse,” she says. “If you look at the times the requests come in, sometimes they are in the middle of the night on a Saturday, because that’s when some people get off work. It’s another lesson for us, in that for healthcare, we need to go where the patient is. I can’t remember the last time I bought a plane ticket that was not my phone, and that’s the expectation people have for healthcare. The technology or tool needs to become invisible so that at no point are you thinking about it.”
Meanwhile, Clark points out that being in CMS’ Bundled Payments for Care Improvement (BPCI) initiative for orthopedics for the last two to three years, has put an increased emphasis on patient engagement as well. Indeed, as these programs are centered on quality outcomes, it behooves providers to have knowledgeable patients.
“Getting into these bundled payments, you definitely want to give a patient a way to say late at night, ‘I had my surgery a week ago and I don’t know if my incision is looking the way it should, so I’m worried.’ How great is it to be able to ask that question late at night when people tend to worry about things?” And then, the next morning, a physician assistant and a mid-level clinician can call the patient back, ask what’s going, what he or she might be seeing, and then discuss what the next steps are, Clark explains. “You don’t want the patient to end up in the ER. You want to get to the problem and handle it early,” she says. “We have had great results [in these models], and that’s so much been about engaging the patient. That’s what success in those programs is based on. Success on a quality outcome is based on dozens of factors that are totally outside the operating room.”