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Health IT: Physicians are the easy part (HIMSS meeting)

Doctors have financial incentives to adopt EHRs. But patients don’t. Physicians are trying to see how to get them to integrate technology into their health.

By — Posted March 25, 2013

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When Geeta Nayyar, MD, an internist and chief medical information officer for AT&T Health, was preparing to leave her New Orleans hotel room on March 3 to give a talk on the use of mobile devices in health care, she quickly checked her Facebook page. There was an urgent message: The city was under a boil-water order because of water-pressure problems.

During her talk at the annual Healthcare Information and Management Systems Society conference, Dr. Nayyar used the message to illustrate her point about the importance of using technology to give instant information to patients. “This information was valuable, because I got it right when I needed it,” she said. Had she not seen the Facebook post, she probably would have taken a drink of potentially dangerous water. “Why are we not doing this in health care?” she asked.

Thanks to the meaningful use incentive program — the promise of up to $44,000 from Medicare or nearly $64,000 from Medicaid for adopting electronic health records, and the threat of a Medicare pay cut if they don’t — the vast majority of physicians are using health information technology even if they aren’t always happy with it. But without an equivalent program aimed at patients, much of the focus at HIMSS’ March conference was about how to get them to use technology to manage and improve their health.

Physicians are front and center in that effort. Meaningful use requirements include getting patients to receive or share information electronically with doctors. But how do doctors get them to do that? As Dr. Nayyar pointed out in her presentation, creating a culture around patient engagement can start with things as simple as sending valuable information to a device a patient already carries — a cellphone. The level of engagement can build from there as the technology advances and as patients get older or sicker and require more from their physicians.

Patient not using portals

For many practices, the first step toward patient engagement starts with a patient portal.

Under stage 1 of the meaningful use program, physicians are required to provide patients with electronic access to their data and the ability to exchange secure messages with their physicians. For the vast majority, this will happen through a dedicated patient portal.

Because of this requirement, the number of practices that have a patient portal has doubled from 20% in 2010 to 40% in 2012, according to a survey by AmericanEHR Partners. AmericanEHR Partners, founded by the American College of Physicians, maintains a vendor-neutral database of EHR products and vendor ratings based on satisfaction reviews submitted by its member organizations, which represent more than 700,000 physicians. The American Medical Association signed on as a member in May 2012.

The organization thought that by making the technology available, patients would take advantage of it, said Judy Murphy, RN, deputy national coordinator for programs and policy at the Dept. of Health and Services Office of the National Coordinator for Health Information Technology. But that didn’t happen.

The Centers for Medicare & Medicaid Services issued a report in October 2012 finding that 70% of physicians who achieved stage 1 requested an exclusion to the requirement that practices needed to provide, to 50% of patients who requested them, an electronic copy of their records within three days. The doctors qualified for the exemptions because none of their patients asked for the records. Stage 2 will require physicians to get at least 5% of patients to access their records online and exchange secure messages with 5% of their patients.

Eric Manley, eHealth system manager at Mayo Clinic, warned physicians that they will not meet meaningful use requirements unless they engage patients through the portal. He offered tips to get patients on board:

Explain it. Manley said that when it comes to things like a patient portal, patients probably will reject it at first. But when they learn exactly what the portal is and how they can benefit from it, they will be more likely to use it.

Promote the portal in the context of a visit or action. When ordering lab tests, tell patients they can access the results online. When patients call for something that could have been done online, such as scheduling an appointment, tell them those functions are available online.

Make the portal the practice’s preferred method of doing certain tasks. Accomplishing tasks through the portal must become an integral part of the practice, not separate or second or third options. If sending patients to the portal to retrieve information isn’t treated as the practice’s preferred method, it won’t become the patients’ first option, Manley said.

Remote monitoring lacks demand

A primary goal of stage 3 of the meaningful use incentive program is to enable physicians to push information to patients, and vice versa. One proposed guideline is for physicians to accept patient-generated data for inclusion in their EHRs. This ability will open the door to more monitoring done outside the traditional health care setting.

When Meridian Health System, a New Jersey-based hospital group, started piloting remote monitoring technologies a few years ago, it quickly found it was going to be a tough sell to many patients, said Sandra Elliott, director of consumer technology at Meridian.

She said a remote monitoring tool should have certain traits, regardless of the technology. It must fit into the patient’s daily routine, be easy to use, be portable, promote self-management, provide ongoing reinforcement, create clinician feedback loop and allow data to be shared with loved ones.

Many of the mobile devices available when Meridian launched a pilot program lacked one or more of these features. So Meridian decided to build its own applications. Since then, apps on the consumer market have continued to improve and are getting closer to meeting all the criteria for a useful monitoring app.

In his keynote address at the HIMSS meeting, Eric Topol, MD, a cardiologist and chief academic officer of Scripps Health in San Diego, demonstrated several remote monitoring apps that were far more advanced than ones he demonstrated at a similar presentation a year earlier.

“Why do we need clinics when so much [monitoring] can be done remotely?” Dr. Topol asked. He said he would like to see a health care system that uses hospitals and clinics only for surgeries and the most critical cases. “The idea of going to your doctor’s office is going to feel as foreign as going to the video store. That is going to happen.” Patients, he said, would prefer to be monitored at home rather than being in a hospital or physician office.

However, that isn’t happening yet, and patients aren’t yet demanding that from their physicians. Health technology experts believe there is one tool that could make that happen: the smartphone.

Connecting with patients through mobile

Because smartphones have become so ubiquitous, it’s a safe bet that a large majority of patients in any practice, regardless of age or income, are smartphone users — or soon will be. A Pew Internet & American Life Project report from February 2012 found that 46% of Americans own a smartphone, and 41% have some other cellphone. Increasingly, anyone wanting to replace a cellphone has no choice — at least from what their carrier offers — but to replace it with a smartphone.

What this means to health care is that more and more people are and will be walking around with devices capable of remote monitoring. This is really important when it comes to the underserved populations, Dr. Nayyar said.

“A lot of times people can afford a phone but they may not necessarily be able to afford a home computer, home Internet service and a phone. So if they had to choose, they would choose a phone,” she said. The Pew report found that smartphone use among those with household incomes less than $30,000 grew from 22% in 2011 to 34% in 2012.

Although the phones have the convenience factor that is crucial to remote monitoring, the piece that’s still being figured out is what to do with the data. Most applications don’t have the ability to send data to a physician’s EHR. Even if it were possible, physicians are concerned with the “data deluge.”

Dr. Nayyar said she doesn’t need the majority of data that will be collected, but it makes sense to track certain trends for certain chronic disease patients. How this data management will take place is being figured out. But many physicians focus on what has not been figured out instead of what they can do to start a culture of patient engagement. Physicians can view mobile devices as an extension of the 10 to 15 minutes the patient gets in the exam room.

“This can be simpler than we think,” Dr. Nayyar said, referring to the Facebook post she received about the boil-water order. She said that with no effort, she received valuable information that altered her behavior and kept her from drinking the water. “This isn’t complicated,” she said.

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Meaningful use as a learning tool

A theme repeated through the Healthcare Information & Management System Society’s meeting in New Orleans in March was that meaningful use is only a foundation for the changes that will transform health care. Or, as health informatics consultant Seth Foldy, MD, MPH, put it: The point of meaningful use is to learn.

He said, through EHRs, physicians can learn about the patient, learn to improve care, learn about multiple patients, learn from research and learn from surveillance. Finally, meaningful use can help physicians “learn how to learn.”

Physicians must treat meaningful use as mastering a new way of doing things, said Leland Babitch, MD, past chief medical information officer at the Detroit Medical Center. “If it doesn’t actually change the way you provide care, one can argue that’s when you get unintended consequences.”

Dr. Foldy shared two startling statistics that underscore the need for computer-assisted learning. First, for the average primary care physician who treats a Medicare population, there are 229 other physicians involved in that population’s care. The only way it’s possible for each treating physician to know what the others are doing is through technology. “That’s an awful lot of connections to learn about and to learn from,” he said.

Second, if physicians who work eight-hour days were to incorporate all the guidelines they are required to follow in the course of a day without the help of technology, their workdays would need to be 21.7 hours long. The exchange of data can help ensure that physicians have the information they need when they need it.

For learning to continue on the right path, physicians need to “look beyond implementation and meaningful use attestation,” Dr. Foldy said.

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