Stage2mu part2-ptengagementtochie-121005114900-phpapp02

Meaningful Use Stage 2 (Part

2) – Patient Engagement, HIE and TOC

Adele AllisonNational Director of Government Affairs

October 25, 2012

888.879.7302 • www.SuccessEHS.com

Stage 2 MU – Infrastructure Wave

Health IT Considerations


4 Marks of Meaningful Use

Adopt and Adopt and Use CEHRTUse CEHRT

Capture Capture DATADATA

Report Report DATADATA

Move Move DATADATA






Move Move DATADATA

Core: Rx

CPOE

Core: Rx

Alerts

Core: Problem

List

Core: eRx

Core: Rx List

Core: Rx

Allergy List

Core: Demo-

graphics

Core: Vitals

Core: Smoking

Status

Core: CQMs

Core: Clinical

Decision Support

Core: eCopy

of Record

Core: Clinical

Summary

Core: Test of

Exchange

Core: Protect

PHI

Menu:Rx

Formulary

Menu:Lab

Results

Menu:Patient Lists

Menu:Patient

Reminders

Menu:Patient

eAccess

Menu:Patient Education

Menu:Rx

Reconcile

Menu:TOC

Summary

Menu:Immun. Registry

Menu:Syndromic

SurveillanceData






Move Move DATADATA

Core:CPOE

(Rx, Lab and Radiology)

Core:Demo-

graphics

Core:eRx and Formulary

Core:Vitals

Core:Smoking

Status

Core:5 CDS and Rx Alerts

Core:Lab

Results

Core:Patient Lists

Core:Patient

Reminders

Core:Patient View,

Download, Transfer

Info

Core:Clinical

Summary (Electronic &

Paper Avail.)

Core:Secure

Messaging w/

Patients

Core:Reconcile

Rx

Core:TOC

eSummary of Care Record

Core:Production

Immun. Reporting

Core:Protect

PHI (Encryption)

Menu:Production

Imaging Results

Menu:Family Health History

Menu:Electronic

Notes

Menu:Production eSyndromic Surveillance

Menu:Production

Cancer Registry

Reporting

Menu:Production Specialized

Registry Reporting

CQMs:Electronic Reporting (EHR Direct Preferred)




Move Move DATADATA



• Cultural Shifto Change is hard → “We’ve

always done it this way.”o Leadership and Professionalism

• Redesign will create temporary Chaos

• Address techno-challenged userso Scribeso Focused trainingo Super-users

• Celebrate your success!




• Workflows must be consistent

• 3 Data-entry Types1. Narrative Text2. Structured Data3. Object-oriented, Codified Data

• Apply the 5-Rights1. Right Information2. Right Person Capturing3. Right Data Format4. Right Technology Channel5. Right Time in Workflow





Move Move DATADATA

• Define your Use Cases o Referral Managemento ED/Hospitalization Notificationo Emergency – “Break-the-Glass”o New/Unknown Patient

• Use Cases → 2 Clear Goalso ↑ Qualityo ↓ Costs

• Interface vs. HIE• Health Information

Exchangeo Sustainability Modelo Emerging Technology


Move Move DATADATA



• Clinical Data Reporting is Crucial!o Drive Reimbursement Reform

under ACA (E.g. VBM)o Physician Compare Website

• CQMs to be electronically submitted by CY2014

• Medicare Data → PQRSo Claims-basedo Registry-basedo EHR Direct

• Medicaid Data → Ind. Stateo Process and Timelineso Interface or HIE


MU2 Health IT Implementation List

• CPOE• Rx Database• Master Patient Index• Patient Administration• Detailed Vitals• Smoking Status• Population Health Mgmt.• Thin-Client Operations• Data Encryption Technology• Internet Enabled Technology• Structured Knowledge Base• Documentation Tools

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

• Evidence-based Guidelines• Advanced Patient Portal• Patient Education• HIE → Direct / Exchange• Bidirectional Lab Interface / HIE• Immunization Interface / HIE• PACS Interface / HIE• Public Health, Cancer and/or

Specialty Registry Interface / HIE• Hosting / Emergency Backup

CEHRT Standard Offerings

CEHRT Extensions





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 Teenso 75% of all Teens text

o Teens average 60 texts per dayo GirlsGirls text more than boys at 100 / day compared to 50 / day

o Black teens text average of 80 / day

• 57% have a Laptop• 19% have a Tablet Computer• 19% Own and e-book Reader

• 52% Adult Americans use phones while watching TV


Plugging into the Matrix• Who: 76% Internet Use in U.S. → Ubiquitous and

Pervasiveo 4.7% Dial-upo 63.5% Broadband

• What: Internet Usageo 62% Social Networkerso 55% Share Photoso 26% Comment / Blogo 15% Personal Websiteo 12% Tweet

• Elderly: 53% of Age 65+ use Internet / Emailo 39% have Broadbando Only 34% of Age 75+ have Internet



• 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 / Reviewso 5% Post Themo CMS → Physician Compare www.medicare.gov/find-a-doctor/provider-

search.aspx

• 18% Source Hospital Reviewso 4% Post Themo 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



• Is Patient Decision-making Affected? Yes!• 49% Influences view of diet, exercise, stress mgmt.• 38% Affected decision about seeing a doctor• 38% Altered way of coping with Chronic Condition / Pain

Area of Advice Sought

ProfessionalFamily, Friends, Fellow Patients

Both Equally

Accurate Diagnosis 91% 5% 2%Rx Information 85% 9% 3%Alternative Treatment 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 Effects of social, cognitive, emotion factors on patient decision-makingo 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 Meaningful Use Stage 2 - 7 Measureso Accountable Care Organizations – 7 Measures7 Measureso NCQA Patient-Centered Medical Home – 66 Factorso Value-based Purchasing – CAPHS


Fed. Programs & Patient Engagement

Proposed Stage 2 Core MeasuresNo. Objective Measure Threshold Exclusions

1Implement Clinical Decision

Support and Track Compliance

Implement CDS to improve on high-priority condition:1.5 CDS interventions for 5 or more CQMs during entire reporting period; and2.Enable drug-drug and drug-allergy checks for entire reporting period.

5 Rules and Rx alerting by attestation

None

2Provide Patients with Clinical

Summaries

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.)

50% (Unchanged)

EP has no office visit during EHR reporting period

3Use EHR for Patient-Specific

Education ResourcesProvide patient-specific education resources to all patients

10% (Unchanged but made Core and “if

appropriate removed)

EP has no office visit during EHR reporting period

4Generate 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) None

5Use of secured messaging with

PatientsSend secured messages to patients seen during reporting period

10%EP has no office visit during EHR reporting period

6Timely Electronic Access to Health

Information

Patients can view online, download and transfer info within 4 days of being available to EP, subject to EPs discretion to withhold certain info

1. 50% of all pts., and

2. 10% of pts. access

EP has no orders / creates info required

>50% visit in county with >50% with 4Mbps broadband avail.

7 Send Reminders to PatientsPreventative and follow-up care for all patients based on clinically relevant info for anyone with an OV in past 24 months

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

Core)

EP has no office visit in previous 24 months


ACOs and Patient Engagement Engagement

• 3333 Quality Performance Measures Quality Performance Measures • 77 Patient / Caregiver Experience Patient / Caregiver Experience

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

in Nov)in Nov)o Patients Option to submit data online Patients Option to submit data online →→ 10%10% submit submit Medical HistoriesMedical Historieso Patient Patient educationeducation in in non-English languagesnon-English languageso 10%10% of Patients ability to of Patients ability to update update and and correct information correct information onlineonline

Measure Method of Data SubmissionGetting Timely Care, Appointments and Information SurveyHow Well Your Doctors Communicate SurveyPatients’ Rating of Doctor SurveyAccess to Specialists SurveyHealth Promotion and Education SurveyShared Decision-Making SurveyHealth Promotion and Education Survey


PCMH and Patient Engagement

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

o Optional with PCMH Recognitiono “Consumer Experience is Critical Component of Quality of Care”o Uses CAHPS PCMH Survey to access:

Access Information Communication Coordination of Care Comprehensiveness Self-Management Support and Shared Decision-Making

PointsNCQA PCMH 2011

Standard and ElementNumber

of FactorsMust Pass?

20 PCMH Standard 1: Enhance Access and Continuity 344 Element A: Access during office hours 4 Yes4 Element B: Access after hours 5 No2 Element C: Electronic Access 6 No2 Element D: Continuity 3 No2 Element E: Medical Home Responsibilities 4 No2 Element F: Culturally & Linguistically Appropriate Services (CLAS) 4 No4 Element G: Practice Organization 8 No

17 PCMH Standard 2: Identify and Manage Patient Populations 353 Element A: Patient Information 12 No4 Element B: Clinical Data 9 No4 Element C: Comprehensive Health Assessment 10 No5 Element D: Using Data for Population Management 4 Yes

17 PCMH Standard 3: Plan and Manage Care 234 Element A: Implement evidence-based guidelines 3 No3 Element B: Identify High-Risk Patients 2 No4 Element C: Manage Care 7 Yes3 Element D: Management Medications 5 No3 Element E: Electronic Prescribing 6 No9 PCMH Standard 4: Provide Self-Care and Community Support 106 Element A: Self-Care Process 6 Yes3 Element B: Referrals to Community Resources 4 No

18 PCMH Standard 5: Track and Coordinate Care 256 Element A: Test Tracking and Follow-up 10 No6 Element B: Referral Tracking and Follow-up 7 Yes6 Element C: Coordinate with Facilities / Care Transitions 8 No

20 PCMH Standard 6: Measure and Improve Performance 224 Element A: Measures of performance 4 No4 Element B: Patient / Family feedback 4 No4 Element C: Implements Continuous Quality Improvement 4 Yes3 Element D: Demonstrates Continuous Quality Improvement 4 No3 Element E: Performance Reporting 3 No2 Element F: Report Data Externally 3 No

100 149 6

66 Direct Patient

66 Direct Patient

Engagement Framework

Engagement Framework

FactorsFactors


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 Patient Engagement was transactional – Financial Focuso 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 Patient Engagement requires a Willing PatientWilling Patient• Patient Portals Patient Portals → → Contagious Contagious and and Effective ToolsEffective Tools• Hub of the Patient, Family, Provider and Staff Hub of the Patient, Family, Provider and Staff CommunicationCommunication

o Web-basedo Secure communication channel with clinicianso Facilitates appointments and Rx renewal

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





Who has ever used an ATM?

Health Information Exchange (HIE)

Transferring of data accurately from one healthcare venue to another.

What is interoperability?

Why is Interoperability so hard to achieve in Healthcare?


ATM Banking vs. Healthcare

ATM Healthcare

Bank to Bank

Account #

Location

Balance

Withdraw Amount

Hospitals

Individual Physicians

PharmaciesLabs

Payers

Public Health Authorities

Patient DemographicsPayer InfoMedications

Lab Results

AllergiesImmunizations

Vitals

Family HistorySocial History

Clinics

Procedures

Diagnostic Center

Nursing Home

Student Health Center

Behavioral Health Dentists

Mental Health

Images

Consult Reports

Discharge Summaries


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

Interoperability Challenges


HIE Success Factors• Early efforts → Some succeeded, some failed • Today → Same success factors apply

Success Factors

Shared Vision with stakeholders

Incremental Approacho Limited initial goalso Build on pilots

Uninterrupted physician workflow

Internet Technology

Strong commitment to Medical Informatics


HIE Guiding Principles

1. Improve Patient Care

2. Increase Operational Efficiency to lower clinic costs

Guiding Principles


Use Cases and Transport Options

Examples

Alerting PCP to ED Visit

Transitions of Care

Referral Management

Query for Documents

HIE Options

Direct

Exchange/XDS

Custom HL7 messages


Direct Example → Referral Management

Consult Referral

Consult Report

Arrhythmia

Jane Doe

Dr. Smith(Internist)

Dr. Heart(Cardiologist)

HISP

HISP


Exchange/XDS Example → Car Accident

CCD RequestCCD

published John Doe

Dr. Smith(Rural Health)

EmergencyUrban Center

HIEHIE

CCD Response


Custom HL7

Custom HL7

Not Meaningful Use Eligible

Custom Development Required

Impacts Cost and Speed of Roll-Out

Typically, evaluated on Case-by-Case Basis

Established pre-IHE Standards → Long-Established HIEs DO NOT use IHE Industry Standards





What is a “Transition of Care?”• Movement of patients from

one provider or setting to another

• Occurs at multiple levelso Within Settings

Primary care Specialty care ICU Ward

o Between Settings Hospital Sub-acute facility Ambulatory clinic Senior center Hospital Home

o Across health states Curative care Palliative

care/Hospice Personal residence Assisted living

(c) Eric A. Coleman, MD, MPH

Referral

Discharge

ALF / SNF


Outpatient

TOC Potential Issues

Patient

ER ICU

In-Patient

Patient

SNF ALF

Personal Medicine List?

Coordinated Care Plan?

Medication Reconciliation?

• Home• PCP• Specialty• Pharmacy• Case Mgr.• Care Giver

Inpatient Discharge Plan?Medication

Reconciliation?Personal Medicine

List?

DischargePlan?

Care 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 Ineffective Transitions → Poor Outcomes and Increased Costs

o 1:5 Seniors (2.6M) readmitted within 30 days of dischargeo 2011 Poor Transitions → $25-45 Billion in wasteful spending

• Hospitalization Hospitalization CareCare GapsGapso Discharge Rx Reconciliationo Lack of Understanding of Discharge Plan of Careo Non-compliance or Untimely Post-discharge Plan of Careo No appointments with a PCPo Logistics (E.g. Transportation)o PCP unawareness of hospitalizationo Lack, delay or inadequate communication with downstream providero 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/Referralso 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 Costso Conclusion: Care Coordination focus a “Must” for sustainable ACO

performanceo 6 ACO Performance measures link to care coordination

• TOC / Referral success will rely upon HIE


MU2 and TOC / Referrals – CEHRT

CEHRT Must• Receive Information• Display in Human-

Readable Format• Accept CCD, CCR and/or

CCDA• Incorporate Rx, Allergies

and Problems• Transport Vehicle: Direct

• Will CEHRT help match correct patient?

Inbound TOC / Referral


MU2 and TOC / Referrals – CEHRT

CEHRT Must• Create the Order• Create CCDA (Contains

elements for Inbound TOC requirements)

• Provider Directory (Standard Not Defined in Regulation)

• Connect to HISP• Send CCDA• Possible Receipt of

Record Confirmation

Outbound TOC / Referral




Tips for Success


5 Tips for Success – Patient Engagement• Tip 1: Measure Patient Satisfaction Pre- and Post-Project• Tip 2: Involve the Provider(s)

o They must drive the medical responseso They are going to get mad with some survey results

• Tip 3: Address Cultural-Change Challengeso “One more thing I have to do!”o “Our patients will never go online”o Creates a mutual interdependence between Providers and Patients

• Tip 4: Add a “filter” and Map the Workflowo Make the workflow someone’s job (Think “Care Team”)o Get Providers into a routine (E.g. See patients, answer emails / flags,

cycle again)o Perhaps schedule time on the Provider’s calendar


5 Tips for Success – Patient Engagement• Tip 5: Promote, Promote, Promote!

o Refine the Message → Faster way to get lab results, refills, etc.; No more Phone-Tag!

o Strategically place Brochures (E.g., Ck-in / Ck-out, Waiting Room)o Add information on appt. reminder cards → “Use our online

scheduling!”o Remind patients of ability to request refills online when they call for

refillso Computer in waiting room to assist patients in registering, completing

paperwork, etc.o Replace “on-hold” music with introduction to patient portalo Add-on announcements with all statements, newsletters and

ePublicationso Improve organizational branding


5 Tips for Success – HIE and TOC

• Tip 1: Define your Use Caseso Does it improve quality?o Does it decrease costs?

• Tip 2: Involve the Stakeholderso Hospitalo Specialty Providers

• Tip 3: Understand your HIE Marketo Statewide / Local Market Progress and Barrierso HISP Providers for Directo Exchange for more advance Query / Retrieve HIE

• Tip 4: Allow ample bandwidth to plan and implemento Data-Sharing Agreements, SOWo Understand related Costs


6 Health IT Tips – Your IT Vendor

• Tip 1: Meaningful Use, PQRS and Other Meaningful Use, PQRS and Other DashboardsDashboards??o Metrics / Analytics by ProviderMetrics / Analytics by Providero Facilitates quick numerators/denominators for MU attestationFacilitates quick numerators/denominators for MU attestationo Clinic analytics with drill-through detailsClinic analytics with drill-through details

• Tip 2: Patient Portal Patient Portal Inherent with System?Inherent with System?o Should be part of Core OfferingShould be part of Core Offeringo Avoids Additional vendor and integration considerationsAvoids Additional vendor and integration considerations

• Tip 3: Single database Single database solution for PM and EHRsolution for PM and EHR• Tip 4: EHR Direct EHR Direct PQRSPQRS• Tip 5: More than just first call More than just first call supportsupport

o Initiative Toolkits (E.g. MU, PCMH, PQRS)Initiative Toolkits (E.g. MU, PCMH, PQRS)o Consulting Support with domain expertsConsulting Support with domain experts

• Tip 6: Ongoing Client Educational Ongoing Client Educational OfferingsOfferings


Added to Added to The BRIEFThe BRIEF or Questions: or Questions:[email protected]@successehs.com

Follow me on Twitter:Follow me on Twitter:www.twitter.com/Adele_Allisonwww.twitter.com/Adele_Allison

Stage2mu part2-ptengagementtochie-121005114900-phpapp02

Technology

marks of meaningful

o leadership

meaningful use stage

use cehrtcore

structured data

timelines o interface

cehrt patient menu

use cehrtmove data888