One of the areas drawing considerable attention among the clinician community (EPs or Eligible Professionals) is the focus on patient/family engagement. Here are the proposed measures:
- Greater than 50% of patients provided online access within four business days
- Greater than 10% of patients view, download, or transmit their record to a third party
- For EPs, clinical summaries provided within 24 hours for >50% of office visits
- Patient-specific education resources are provided to patients for >10% of all office visits
- A secure message was sent by >10% of patients using the electronic messaging function
Of these proposed measures, #2 (view, download, transmit) and #5 (secure messaging) stand out because each one would place the EP at risk for the behavior of their patients. In other words, unless 10% of the patient population view or download or transmit their record, an EP would fail the MU “test.” Likewise, unless more than 10% of the patient population initiate a secure message to the EP, the EP would fail Meaningful Use. Failing MU means loss of all of the potential EHR incentive dollars available for Stage 2. While this is true for any of the measures for MU, these two are the only measures that depend on the behavior of patients and which are significantly beyond the control of the EP, practice, and his/her team. It is for this reason that the measures are receiving more scrutiny.
Physicians are typically very supportive of engaging patients and their families (when appropriate) in their care, and many probably wish their patients were more involved. The modalities (e.g. patient portal, secure email, clinical summaries) advanced by the proposed Stage 2 measures are typically part of enhanced efforts by patient-centered medical homes. Many offices have already invested time and money into developing patient portals, email access, and other innovative patient engagement strategies. However, there has been variable uptake by patients of these new access and engagement opportunities. Physicians report that, over time, interest and activity typically grows, but it is not predictable despite survey data suggesting that many patients are interested in these options. While surveys of consumers typically indicate better access to the Internet in under-served populations and among older patients than physicians might expect, physicians stil doubt that many of their older patients would be interested using these features of Meaningful Use.
If the measures remain as written, measure #2 would probably not be met if the physician logs into the patient portal (as the patient) to demonstrate the portal and explain its importance in the context of a visit — which would be a prime opportunity to highlight the features and importance. Even if it did “count,” the workflow implications (i.e. lengthening of the visit or commitment of staff time) make these options a challenge. A kiosk or other location for the patient to explore the portal in the practice would also be a possibility. However, that would likely be expensive, necessitate new workflows and office organization, and could undermine patient privacy (especially if it is a small practice without an area for private viewing). Further, would patients who are finished with their appointment want to delay their exit in order to view the record? Would they come early enough to spend the time with this technology prior to the scheduled visit?
With respect to measure #5 (secure messaging), one option could be for the EP to initiate an email to patients with a message that would prompt a reply to the EP. Whether this would count towards the measure is unclear — but the Health Information Technology Policy Committee Meaningful Use Workgroup (HITPC-MU Workgroup) suggested clarifying this point. Another question is whether it would count if the email from the EP to a patient resulted in both a secure email to the EP and included specific directions to the patient directing him/her to access the online record in order to view a new result or message from the practice. Would this EP-initiated email resulting in a secure message and the patient viewing his/her online record count towards both measures? There was debate at the HITPC-MU Workgroup call about this with some indicating that this would be “double-dipping.” Clarification is clearly warranted.
Should the expectation be placed on the EP rather than patients to initiate secure messaging? Many practices that introduce email messaging prefer to do so for administrative issues before providing access to clinicians for medical questions due to the concern that patients might rely on email for communicating urgent or emergent clinical concerns. Meaningful Use could encourage ramping up of secure email messaging by placing the responsibility on the practices and allow them to test different strategies for engaging patients starting with important administrative issues (e.g. appointments, referrals, medication refills, etc.).
Finally, should the Stage 2 measures remain as written, how would patients receiving care from multiple EPs (i.e. a patient with a primary care clinician and several specialists/subspecialists) deal with appeals from each practice for them to view/download/transmit from the practice’s online portal and to send a secure message to each of their physicians? In essence, there would be competition for each patient’s “engagement” but what value would there be for patients being pressured to access multiple different portals each of which with a slice of their record — perhaps with the primary care clinician’s record being the most complete?
What does your current practice do to engage patients using technology? How would your practice manage the requirements of these proposed measures should they remain as written? How would you modify the measures to ensure that they achieve their intended goals?
This post is the personal opinion of the author and does not necessarily reflect the official policy or position of the American College of Physicians (ACP). ACP does not endorse a specific EHR brand or product and ACP makes no representations, warranties, or assurances as to the accuracy or completeness of the information provided herein.