Computer with email

Stage 2 NPRM Patient Engagement Measures — Too Much Too Soon?

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:

  1. Greater than 50% of patients provided online access within four business days
  2. Greater than 10% of patients view, download, or transmit their record to a third party
  3. For EPs, clinical summaries provided within 24 hours for >50% of office visits
  4. Patient-specific education resources are provided to patients for >10% of all office visits
  5. 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.


5 responses to "Stage 2 NPRM Patient Engagement Measures — Too Much Too Soon?"
  • April 23, 2012
    sherry reynolds @cascadia

    You don’t “engage” patients after the fact you “design” the system around their needs.

    Practices with the highest rates of adoption in the country (like Group Health Cooperative) started with the patient portal, email access to care team, labs, pharma and now appts and radiology results.

    The key was to provide real value to patients with almost real time data (24 hours and in some cases real time not a 4 day delay)

    It is interesting how often we hear in the same article the unfounded fear that patients might ask too many questions at the same time we struggle to engage them?

    Recent research with the OpenNotes project showed that even homeless people can handle seeing their clinical notes.

    The key is to provide value to your patients not simply ask them to perform a task so that the provider can qualify for MU.

  • April 24, 2012
    Alan Brookstone, MD

    My sense is one of just being overwhelmed. While the value in being able to access information, clinical notes and data is becoming clearer as more evidence expounds the benefits, there is a significant amount of change on the provider side that is taxing capacity to deliver care.

    I believe that patient engagement will continue to grow as users become more comfortable with the tools at their disposal, however it is a learning curve and applying too much pressure too quickly can also be counter-productive.

  • April 29, 2012
    Arvind Cavale

    The whole idea of MU as dictated by CMS is insane and should be completely eliminated. Value to each patient is different under different circumstances. This is the slippery slope once we allow bureaucrats to decide on MU.

  • April 30, 2012
    Alan Glick

    Dr. Barr accurately highlights the challenges of obtaining the MU incentives when relying on patient behavior. I understand the frustration echoed by Dr. Brookstone and Mr.(?)Cavale, but mostly I appreciate the spirit of Ms. (?) Reynolds. Unfortunately, the only way to move EHR use forward was through a (flawed) payment-incentive driven mechanism like MU. The EHR adoption rate would not even be close (probably not 1/3) to what it already is now without MU and we also would not have the exciting and increasingly valuable innovation (including patient engagement technologies) being developed to support EHR.

  • May 3, 2012
    Arvind Cavale

    Very interesting comment, Alan. I am actually a doctor, one that has had an electronic office for almost 10 years; way before CCHIT, not to mention MU. I believe each practice must decide on conversion to EHR based on what value it perceives itself and to its patients. Simply increasing adoption of EHR’s with incentive dollars is exactly the wrong way to go. I see more and more practices adopting EHR’s for this sole reason and cursing themselves for it, because it did not help improve their efficiency and their patients are upset about how IT has changed their doctor’s approach to care…for the worse.

    Since I am considered somewhat of a pioneer in this field, when people ask me “should I got for it to get the MU money?” I quickly advise them against it, unless they go in for the right reasons. The only “meaningful” way to reward practice that effectively digitize is to allow them better reimbursement rates for their services. In other words, let medical practices work like any other for-profit business; allow the cost of IT improvement be passed on to the consumers of the service. This would not only save taxpayer money, but everybody would have a stake in making the system better. Good intentions do not justify a flawed process.

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