Doctors for years have struggled to get people to change unhealthy behaviors and to care about their own health. Yet people continue to smoke, eat poorly, neglect to fill prescriptions and avoid preventive care.
Various health care reform initiatives, including the imperative for accountable care under the Patient Protection and Affordable Care Act – commonly known as Obamacare – as well as the shift from paper to electronic record-keeping, might not get people to ditch their bad habits, but these changes are forcing providers to get creative, lest they get hit where it hurts the most: in the pocketbook.
Notably, the $27 billion federal incentive program for "meaningful use" of electronic health records (EHRs) moves into its second of three phases as soon as Oct. 1 for some hospitals.
In Stage 2, providers have to offer at least half of their Medicare populations online access to their own records and, significantly, 5 percent of these patients actually have to log in and either enter their own data or send unsolicited messages back to providers.
For the first time, there is a financial incentive to "engage" patients in their own care: Hospitals and health care professionals must meet all the requirements or they lose out on extra Medicare and Medicaid payments (there is no partial credit). That has a lot of executives concerned.
"Having a physician penalized for something a patient doesn't do is troubling," says Dr. Howard J. Luks, chief of sports medicine and arthroscopy at Westchester Medical Center in Valhalla, N.Y.
A strong proponent of social media in medicine, Luks publicizes his email address and Facebook, Twitter and Google+ accounts on his website and on his business cards. The response has been underwhelming. "The number of people who reach out are very low," Luks reports. He forges ahead because he sees the promise of patient-doctor communication.
As an orthopedic surgeon, Luks encourages post-operative patients to send him photos to show how incisions are healing. "I have picked up blood clots earlier than I would have had I not been available electronically," Luks says.
Post-op and post-acute care is where a lot of providers are looking to meet that 5 percent requirement, especially since Medicare no longer pays for certain "preventable" readmissions within 30 days of hospital discharge. Many also see potential in engagement platforms such as Web portals and patient-controlled personal health records (PHRs) for patients with chronic diseases.
A portal is great for delivering test results, for post-surgical care, patient education and for patients to ask questions, according Charles E. Christian , vice president and chief information officer at St. Francis Hospital in Columbus, Ga. "I think it's going to be a source of information for patients who have a lot of questions after they leave the hospital," he says.
The bottom line, according to William Montgomery, VP and CIO at Springfield, Ill.-based Hospital Sisters Health System, is that patients will use a portal or a PHR if they perceive value in doing so.
Hospital Sisters, which has 13 hospitals in Illinois and Wisconsin, is trying to provide some value by working with a pharmacy information service called Surescripts to collect and deliver complete, up-to-date medication histories to patients via personal health records tied to the organization's EHRs. This, Montgomery says, helps eliminate the need for individuals to keep their own medications lists current, saving time, hassle and, potentially, lives.
Value also applies on the provider side. In a traditional fee-for-service reimbursement model, doctors won't bother with portals, PHRs or patient-supplied data unless they get paid for their time. Accountable care and "bundled" payments for managing entire episodes of care flip this around, shifting risk from insurer to provider.
"You're really going to get the value if you're in a risk environment," Montgomery says. He suggests that online communication could be a convenient alternative to office visits for chronic disease care or routine follow-ups.
Indeed, Tim Smokoff, chief executive officer of Numera Inc., a Seattle company that specializes in patient engagement through telehealth and online social connections, recommends that providers focus on aging in place – keeping older people in their own homes rather than in long-term care facilities, usually with the aid of monitoring technology – as well as management of chronic conditions and post-acute care. "They are going to get more than 5 percent if they invest in those areas," Smokoff says.
"In this demographic, we don't talk as much about patient engagement as we do care-team engagement," Smokoff says. Care teams might include physicians, nurses and other case managers, pharmacists, physical therapists, family members and patients themselves. "It's really about keeping people healthy and in their homes and out of the hospital," he says.
Christian envisions portals and PHRs as focal points for wellness and care coordination. "The patient portals are going to be platforms for collaboration and communication" among providers and between providers and their patients, he says.
"The patient portals can be windows for additional information that could be germane [to patient care]," Christian continues. "You can make it as powerful as Facebook is." Christian mentioned PatientsLikeMe, a networking site for patients to share advice with others who have similar health issues.
"You are trying to give people experiences," Christian said. "These portals can be a good source of good, quantified information."
They can be, but Christian believes the technology has to be simple to use. St. Francis has multiple EHR vendors and could present some patients with as many as five different portals across various departments, centers of excellence and an assisted-living facility.
"How many portals does a patient need?'" Christian wonders. "For me, the vision is to create one, consolidated place where all this information can be."
The information also has to be relevant and easy to understand. Plain English – or Spanish, or Mandarin – matters because the average patient is likely to struggle with medical jargon. "As clinicians, we're trained to make everything sound erudite, and it's not necessary," says Dr. Joseph C. Kvedar, founder and director of the Center for Connected Health at Harvard University-affiliated Partners HealthCare in Boston, which encourages the adoption of technology to move care into people's everyday lives.
He recommends either retraining physicians to speak in lay language, have software translate what they say, or both. "Fundamentally, we have to be more understandable," Kvedar says. Patients certainly could be offended or falsely reassured as they start gaining access to their own medical records. "We are very candid in records and we're objective," Kvedar says. For example, a doctor might tell someone fighting cancer, "We think we got it all," Kvedar says, even though the record could still indicate the presence of a tumor.
"Fundamentally, we have to be more understandable," Kvedar says. "There's a lot of opportunity for us to clean up our game."
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