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Tuesday, March 20, 2012

Patient Engagement is a two-way effort in MeaningfulUse Stage2

This question came to me via Linked In:
I know CMS is trying to push patient engagement, but how can a practice/provider prove 10 percent and, also, why only 10 percent if it is made available to half of patients?

Secondly, this means meeting meaningful use hinges on the patients and is out of the provider’s control. Is that fair? If they are not engaged, they are not engaged. And what if patients are not wired to see and access their records, such as rural areas?
Before I get into details, let's look at what the rule states:
§495.6 (j)(10) Provide patients the ability to view online, download, and transmit their health information within 4 business days of the information being available to the EP.  
  1. More than 50 percent of all unique patients seen by the EP during the EHR reporting period are provided timely (within 4 business days after the information is available to the EP) online access to their health information subject to the EP's discretion to withhold certain information
  2. More than 10 percent of all unique patients seen by the EP during the EHR reporting period (or their authorized representatives) view, download , or transmit to a third party their health information  
§495.6 (l)(8) Provide patients the ability to view online, download, and transmit information about a hospital admission
  1. More than 50 percent of all patients who are discharged from the inpatient or emergency department (POS 21 or 23) of an eligible hospital or CAH have their information available online within 36 hours of discharge
  2. More than 10 percent of all patients who are discharged from the inpatient or emergency department (POS 21 or 23) of an eligible hospital or CAH view, download or transmit to a third party their information during the reporting period
There are actually four points the querant addresses:
  1. How to prove 10%
  2. Why 10% if only half have access
  3. Fairness of judging providers on patient behavior
  4. Lack of Broadband Access
Broadband Access
I'll address the last one first.  There is an exclusion for lack of broadband access in the rule.  It says:
Any EP that conducts 50 percent or more of his or her patient encounters in a county that does not have 50 percent or more of its housing units with 4Mbps broadband availability according to the latest information available from the FCC on the first day of the EHR reporting period may exclude only the second measure.
This means that if the provider does not have access to broadband, they can exclude the measure.  The problem with this exclusion is that it isn't the providers access that should be the reason for the exclusion, rather it should be the patient access.  I'd reword the exclusion as:
Any EP that conducts 50 percent or more of his or her patient encounters in a county, or with patients who live in a county that does not have 50 percent or more of its housing units with 4Mbps broadband availability according to the latest information available from the FCC on the first day of the EHR reporting period may exclude only the second measure.
In that way, provider could be excluded based upon where the patients who would need to access the information live, rather than where the provider is located, as well as being excluded if the provider doesn't have access.

Proving the 10%
Now, back to the first item:  On how to prove the 10%.  In order to claim "Meaningful Use", the provider must use the certified technology.  This is noted in the Discussion of the Relationship of Meaningful Use to Certified EHR Technology in the Incentive rule.  In 314(g)(1) of the Standards and Certification rule, the Certified EHR technology must be able to electronically record the numerator for each meaningful use objective with a percentage-based measure.  So, how to prove it?  Ask your EHR.

Why 10% and 50%?
Why should the measure be 10% if only 50% have access?  Actually, that's a logical conjunction not made by the rule.  There are two measures:  At least 50% must have access, and 10% must do something with that access.  A smart provider will be sure to provide as many patients as possible with access.

Is it Fair to Judge providers on what patients do?
Finally, on the fairness of judging providers based on their patient's behavior:  Engagement is a two way street.  It takes both parties to create engagement, not just one or the other.  Given that the incentive rule is giving providers $ to show that they are doing something meaningful, judging them on a meaningful outcome that shows patients are engaging is certainly fair, at least in my viewpoint.

Arguably, 10% could be challenging for some providers (including specialties).  I think the key for this  objective is to make a meaningful effort to engage with patients, and you could judge that effort based on the number of responses you get.  In marketing, expecting 10% response rate is rather difficult.

I would argue that this objective should be a fixed number, such as 200 patients, rather than a percentage of the patient population.  Ten percent will be difficult to reach for some specialty providers, especially for those whose patients will also have access to the same information via their GP.  Making the measure a significant number of patients will ensure that all providers attempt to engage meaningfully with their patients without making it overly difficult for specialty providers who are at a disadvantage due to the transitory nature of their patient relationships.  Making the number significant (like 200), means that half-hearted attempts at engagement won't do, and it still would achieve the CMS goal of getting patients engaged.

What do you think?



6 comments:

  1. In my opinion, it is fair to judge primary care providers on what their patients do.

    One of the significant issues in primary care is patient compliance with self-care, especially for chronic health conditions, and medication. This figures into care outcome and population health metrics. Patient compliance with use of electronic tools that will benefit them is in the same category. And 10% compliance is a reasonable first step.

    But I think the more relevant measures -- ones that need to make PHR vendors accountable -- are useability criteria for both patients and providers. It is unfair, and unhealthy, to have a PHR that is difficult to use. I'd *love* to see a concerted effort for improvements in this arena.

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  2. My issue is that broadband access (as defined, it only means that one 'could' buy a connection) doesn't cover it. What about patients who can't afford to shell out $150/month to Comcast, or even to own a computer in the first place? I don't foresee HIV many patients wanting to access their records at a public library, for example.

    What about patients whose primary language isn't English?

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  3. I agree w/your rewording re: broadband access to look more at the patient's residential location vs. the location of the care given. However, it's probably a lot simpler for each provider to declare presence of the broadband at his/her point of care vs. analyzing broadband access at the patient's residence.

    Regarding patient engagement and physician burden, I was initially wondering whether the verbiage "...upon request" would be more appropriate in the measures, emphasizing the capability to meet those requirements, should a patient care to engage. But your post and Glen's add-on opinion made clear to me that pushing providers to promote engagement is indeed at the crux of the term 'meaningful'! As such, the 10%, while loose, is probably a good number as a carrot, with enough wiggle room for challenges such as non-English, no computer, no broadband even if available. Having worked on some mobile health intervention applications for rural/impoverished areas, I know there ARE means to make available in formats (languages, delivery methods) that folks ARE able to obtain (computer/smartphone/SMS).

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  4. The numbers did change in the final rule, but the ideas in this post are the same. If you really want to hit 5% OR more, put a kiosk in your office for a month and hire a student to train patients on how to access their record via your portal. If half your patients in a month access the portal because of this, you will probably reach your numbers for the year.

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    Replies
    1. And I'll point out, where doesn't matter, it's how. If they access the portal from your office, the access still counts towards your 5%.

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    2. Great idea. Please give me some advices on how such a demo scenario for training patients on the fly could looks like?

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