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April 2017

EHR Insider: Patient Engagement Proving to Be Tricky
By Dan Golder, MD
For The Record
Vol. 29 No. 4 P. 5

In a December blog post, Kate Goodrich, MD, MHS, director of the Center for Clinical Standards and Quality at the Centers for Medicare & Medicaid Services (CMS), wrote that patient engagement is designed to "strengthen person and family engagement as partners in care." This indeed summarizes CMS' goal for patient engagement—namely increasing patients' participation in their own care and enabling them to become partners as well as stakeholders in the process. CMS' "Person and Family Engagement" strategy focuses on and expands this partnership concept.

With the advent and evolution of meaningful use and the recent introduction of the Merit-based Incentive Payment System (MIPS) and the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), providers know a portion of their reimbursement will be tied to these initiatives, which include stipulations on patient interaction with EHRs. In short, to receive full payment from Medicare and Medicaid, providers and hospitals must encourage patients to adopt technology and become active partners in their care.

In general, the patient engagement efforts currently associated with CMS' regulatory programs fall into a small number of similar activities. While there are slight differences in measurements and thresholds, the essence of the patient engagement objectives remains relatively consistent among all programs.

View, Download, or Transmit
One of the earliest forms of patient engagement, view, download, or transmit has its roots in stage 1 of meaningful use, which required that patients be provided access to their health information. It has since evolved in the latest stages of meaningful use and with the advent of MIPS and MACRA.

In short, patients must be able to access and use their electronic health information, most commonly by transmitting it to a third party. This typically involves the use of a patient portal to access a subset of the information stored in the EHR.

Electronic Access to Health Information
Similar to view, download, or transmit, this objective, which also stretches back to stage 1 of meaningful use, requires that patients be provided access to their health information within a set period of time (36 or 48 hours, depending on the program).

Typically, this involves giving patients access to an online portal, although CMS does not constrain providers from using other methods to meet this requirement. Indeed, as CMS pushes for more adoption of application programming interfaces (APIs), the need and/or utility of patient portal access may become less common.

Either way, this metric attempts to ensure there is accurate and timely health information available to patients in an electronic format.

Direct Secure Messaging
Secure messaging allows patients and providers to communicate while ensuring the privacy and security of protected health information. The idea is to avoid the use of public e-mail systems for health information exchange.

As this metric evolves, the expectation is that patients will respond to secure messages and bidirectionally communicate with providers about their health care status and treatments.

Patient-Generated Health Data
A newer requirement, this metric reflects the growing use of personal health devices. Providers are expected to incorporate information from smart devices such as glucometers and fitness trackers into the EMR.

There is great potential here to be more proactive with patient heath information and, subsequently, patient care. As smart devices develop the ability to actively transmit data, the potential exists that triggers can be set to alert a physician when a particular reading occurs (for example, when a patient's glucose rises above a certain value), which may result in better, more timely care.

Access to Health Data via APIs
One of the newest requirements is the use of APIs for providing programmatic access to EHRs. API use, which is more of an indirect component of patient engagement, affords external third-party applications access to an EHR and patient health data.

Envisioned both as a way to help facilitate information transfer and eliminate information blocking, APIs are promoted as a method to enable smart devices and apps to use and manipulate health information in novel ways.

While APIs offer great potential for future integration, how they may ultimately improve patient engagement remains to be seen. For now, CMS seems to be content with mandating their availability, hoping this will stimulate innovation by software developers.

What Has and Has Not Worked
Although most experts would agree that active patient engagement with EHRs is ideal, promoting adoption via regulatory statute has proven to be less welcome and met with some controversy.

Originally, stage 2 meaningful use measures had higher thresholds for the various measures of patient engagement, which proved to be difficult for providers to meet, especially considering they were depending on patients to actually achieve the thresholds.

In response, CMS reduced the thresholds through modifications to meaningful use requirements as well as in the current MIPS regulations, where the 2017 standard requires one patient to participate in engagement activities. This essentially makes the metric a proof of concept, ensuring that the technical infrastructure is up and working.

In future years, CMS is expected to increase the requirements (any technical hurdles will have presumably been solved) to encourage more robust patient engagement.

Technical Challenges
For some providers, the technical ability to promote the various components of patient engagement were achieved easily. However, for many—especially those in rural areas—technical limitations to infrastructure remain a barrier.

Many of the metrics specified by CMS have been dependent on the implementation of a patient portal. While initial metrics required that a portal (and relevant health information) was available, patient engagement efforts have evolved to the point that it is clear that patients must be able to use and interact with the portals. For this to be successful, patients must have access to the appropriate technical infrastructure and the technical acumen to feel comfortable interacting online or via a mobile app.

Lastly, portals tend to be vendor specific. As a result, patients visiting multiple clinicians in multiple locations may find their health information scattered among several portals, each with their own log-on requirements and learning curve and lacking a composite, patient-centric view of their health information.

Provider Challenges
Given the link between reimbursement and successful patient engagement, providers must encourage patients to use portals and interact with their health information. Provider encouragement can help improve patient adoption, yet many providers feel that promoting portal use is not a valuable use of their time.

Providers have similar concerns about the amount of time needed to encourage patients to use secure messaging and the potential ramifications of bidirectional communication, which they believe could result in hours spent each day responding to patient questions.

Patient Challenges
Perhaps the most prevalent barrier for improving patient engagement lies with the patients themselves, who are often not ready to interact with their electronic medical information.

Patients may struggle with the portal's structure or lack the technical acumen or comfort level to access their health information online. Simply registering for access can be complex and nonintuitive, requiring patients to take multiple steps outside of the provider's facility. While some providers help patients register while they are in the office, a significant number do not.

In many cases, patients receive a registration code (often printed on the After Visit summary) to enroll in a portal. While this is a relatively straightforward task, it nevertheless can be daunting to patients uncomfortable with technology. Registration may also involve downloading an app or other technical requirements. In addition, the portal may not be supported by the physician's office, making the software vendor the only option for help.

Besides the intricacies of joining a portal, there are other factors potentially even more difficult for patients to overcome. For some patients, cultural barriers may affect their motivation, willingness, and ability to engage with their health information. Additionally, many patient engagement activities assume a level of health literacy, as well as a level of health status and functioning. For example, elderly patients in cognitive decline may not be able to effectively interact with a patient portal.

Patients also may be traditionalists who view the physician as being the person in charge, the ultimate decision maker. These individuals do not view themselves as being able to contribute to improved care; they are more comfortable and willing to rely on and trust the expertise of their physician when making critical health care decisions.

Clearly, social and community norms are secondary factors that can influence a patient's ability to comply with patient engagement activities.

Finally, patients, who must find utility in a patient portal or a mobile app, must value patient engagement activities. For example, providing administrative functions such as appointment scheduling and viewing lab results may not carry as much weight as custom portals tailored to a patient's specific interests and needs.

What's Next?
The future of value-based care initiatives will rely on comprehensive, integrated information. Patient engagement activities will contribute to this library of information, as well as validate data received from various sources.

Additionally, APIs hold much promise. Using APIs, entrepreneurs may devise a simplified user interface, allowing access to multiple data sources through a single app and alleviating the need of patients having to traverse several portals.

To promote these changes and encourage innovation, financial incentives will need to become aligned. Incentives should promote a proactive rather than a reactive collection of information and reward clinicians for preventive rather than episodic care.

Patient engagement is neither a panacea nor a quick fix to health care's woes. Some patients and clinicians are more comfortable using the traditional paradigm of a paternalistic clinician and system. Encouragement will be needed for both patients and clinicians to help foster awareness regarding the benefits of patient engagement.

— Dan Golder, MD, is principal of Impact Advisors.