Raising the Stakes: Stage 2 Meaningful Use Requirements Emphasize Patient Engagement

Transcription

1 Raising the Stakes: Stage 2 Meaningful Use Requirements Emphasize Patient Engagement Thoughtful integration and use of patient education in the EHR can help you get there. March 2013

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3 No matter what the original topic quality of care, health disparities, health outcomes, patient safety, shared decision making, cost of care, even revenue cycle management the discussion eventually finds its way to patient engagement. Building patient education into your electronic health record system can help engage patients in their care. The February 2013 issue of Health Affairs heralds the New Era of Patient Engagement. The issue contains more than 25 articles exploring different aspects of patient engagement, including its effects on health outcomes and quality of care, the role of clinicians, and the role of technology. Authors include leading experts on patient activation (Judith H. Hibbard and her team at the University of Oregon), the director and staff members from the Office of the National Coordinator for Health Information Technology (ONC) and CEOs and CFOs from the health systems leading the way to more patient-centered care (Kaiser Permanente, Partners HealthCare and others). There s good reason for so much high-level attention to this topic. As more treatments and procedures are performed on an outpatient basis, and as more patients become afflicted with chronic disease, patient engagement is more important than ever before. Patient engagement facilitates early detection of declining health, improves the chances of successful treatment, reduces readmissions after hospitalization, and improves quality of life. In one article co-authored by no fewer than 12 CEOs of major health systems, the writers state: For CEOs of health care organizations, the move toward engaging patients in their own care is not simply the right thing to do. It is quickly becoming the norm amid growing evidence that patient-engaged care is associated with better health outcomes, better care experience for patients, and lower health care costs. The requirements for Meaningful Use of health information technology reflect the growing realization of the importance of patient engagement. In the Meaningful Use Stage 1 requirements, two core measures and three menu set measures addressed patient education, a key component of patient engagement. Stage 2 raises the stakes considerably To achieve Stage 2, providers must show that 5 percent of patients have viewed, downloaded, or transmitted to a 3rd party their health information. That means achieving Meaningful Use depends not only on the capabilities of your electronic health record system. It depends on the actions of your patients. It depends on patient engagement. The ehealth team at the ONC sums it up in the 3 As: Patients need ACCESS to their health information, which enables them to take ACTION based on that information. At the same time, both patients and providers must shift ATTITUDES in order to share information and work together more effectively. The move toward engaging patients in their own care is quickly becoming the norm amid growing evidence that patient-engaged care is associated with better health outcomes, better care experience for patients, and lower health care costs. Krames StayWell 3

4 Meaningful Use Requirements for Patient Education/Engagement Stage 1 core measures: + Provide patients with an electronic copy of their health information within 3 business days for 50 percent of patients who request it + Provide clinical summaries for patients at each office visit within 3 business days for 50 percent of visits Stage 1 menu set: + Send reminders per patient preference for preventive/follow-up for more than 20 percent of patients aged 65 or older or five years and younger + Provide timely electronic access to their health information to at least 10 percent of patients within 4 days of the information being available to the eligible provider + Use EHR to identify patient-specific education resources for more than 10 percent of patients seen by the provider In Stage 2, patient engagement moves front and center as the menu set measures become core requirements and the emphasis clearly shifts to building systems that encourage patients to become more active partners in their own care. The Stage 2 requirements for patient education/patient engagement include: + Provide summaries to patients within 1 business day for more than 50 percent of office visits (moves from menu set to core set and time is reduced from 3 days to 1 day) + Provide patient-specific educational resources (moves from menu set to core set) + Provide online access to health information within 4 business days to 50 percent of patients after the information is available to the eligible provider and ensure that 5 percent of patients view, download or transmit to a 3rd party their health information Where We ve Been and Where We re Going The problem is not that people don t care about their health, or that they re not spending time thinking about what it takes to be healthy, says Steve Wilkins, MPH, a health care consultant in San Jose, CA, whose blog Mind the Gap focuses on patient engagement and physician-patient communication. He points to surveys that show that more than 80 percent of Internet users have looked up health information online and 82 percent of American adults have had contact with a health care professional within the past year. Engagement to me is being involved in something, and one of the criteria for being involved in something is investing some cognitive or thought power, says Wilkins. 4 Krames StayWell

5 Just showing up at the doctor s office requires a fair amount of cognitive involvement, Wilkins says. First, a person has to detect that something may be amiss. He or she may talk to friends and family about it or look up the symptoms online and determine if they warrant a visit to the doctor. Then, if the person does not have a regular health care provider, he or she has to find a physician who takes insurance and has an appointment available at a time and place that works. Then the person has to get to the appointment, arrive on time and wait for his or her name to be called. I would argue that patients who present in the office, by definition, are already engaged, says Steve Wilkins. The real question is, how engaged they will be when they leave the doctor s office? That, he says, depends upon the communication and engagement skills of clinicians. In an article written by leading health policy researchers in the February 2013 Health Affairs issue, the authors explain that patient engagement is a continuum that ranges from a provider-defined agenda with patient input to truly shared power and responsibility for defining agendas and making health care decisions and all the levels in between. Different patients and different settings will call for different levels of engagement. The range of opportunities along the continuum is best determined based on the topic at hand and defined and created with patients participation, the researchers write. The Center for Advancing Health (CFAH), a non-profit advocacy and health information group based in Washington, DC, defines engagement as actions individuals must take to obtain the greatest benefit from the healthcare services available to them. CFAH s Engagement Behavior Framework outlines upwards of 40 different behaviors in 10 categories that patients should perform in order to get the benefit of the health care system. Patients abilities and willingness to follow through with these actions depend on a host of factors, including their knowledge of their condition, financial situation, geographic location, access to transportation, attitudes and beliefs about health and health care, health status, as well as access to health information and ability to understand and act on that information. Wilkins points out that this requires moving away from the traditional clinician-patient roles. From childhood, people are socialized into the sick role where the doctor is the expert and does most of the talking. The patient s role is to passively sit by and listen to what the doctors say. Even the most empowered among us revert back to this sick role behavior upon entering the doctor s exam room, Wilkins says. He contrasts this with the patient-centered approach in which clinicians take into account the patient s own beliefs, motivations, definitions of health and what constitutes health. It s a big change, but it s worth the effort. As doctors begin to adapt and adopt more of these patient-centered techniques, patient-physician relationships will improve, patients will become more adherent, Wilkins says. Patients then are open to Krames StayWell 5

6 being taught self-care management skills, which is another way of saying it can move them up their level of activation, he adds, referring to the Patient Activation Measurement scale developed by Hibbard. In order to move patients to the appropriate spot on the engagement continuum, providers need to meet patients at least halfway. Access to clear, concise and actionable health information can help with that process. Patient Education Sets the Stage for Patient Engagement Access to information is one of the cornerstones of the Meaningful Use requirements. When patients have access to relevant, clear and actionable information, they can become active partners in their care. Building patient education into the EHR sets the stage for patient engagement in a variety of ways. Elevates clinical importance of patient education and builds it into the clinical process Effective systems use the information entered into the EHR to generate suggestions for relevant patient education materials. This not only helps ensure the information is geared for that particular patient and situation, it ensures that the patient education step doesn t get skipped. For example, after a visit to the emergency department, patients may get a quick one-page summary that explains the findings, gives them self-care tips and signs to look for and reminds them to follow up with their primary care physician. [The information] is right there and you can attach it to the after-visit summary. The whole thing is legible and patient friendly, says Lisa Sanders, MS, Patient Education Specialist at Essentia Health, a rural health system of 18 hospitals and 68 clinics spread over 50,000 square miles of Minnesota, North Dakota, Wisconsin and Idaho. Essentia uses Epic s EHR system and, in May 2012, integrated patient education materials from Krames StayWell. Using a similar patient education setup and the same integrated content with his Meditech EHR system, Richard Westgate, MSN, RN, director of the Emergency Department at Williamson Medical Center in Franklin, TN, can say with confidence, Seventeen percent of our patients are admitted. The rest all walk out with education material from the ER. Encourages standardization, consistency of information across the organization Nothing precipitates disengagement like confusion. Patients who receive conflicting instructions from a provider are more likely to give up than engage in their care. Creating a consistent message in a small hospital is difficult enough. The challenge is huge at Banner Health, which operates 23 acute care hospitals and health care facilities with 36,000 employees in seven states. According to Theresa Lindahl, RN, BSN, Patient Education Team Lead for Banner Health, integrating Krames StayWell patient education into Banner s Cerner EHR system has helped standardize the process so they re giving consistent messages in a common language that is at a literacy level that patients can understand. 6 Krames StayWell

7 Banner had an on-demand patient education solution before, but some clinicians and departments still found other materials to use in their practices. Now, because the information is right there in the EHR, more departments are seeing the benefits of using the same materials used in other areas of the health system. Now that [clinicians] know that this is the standard product across Banner, they re not as apt to go out and find other materials, Lindahl says. As a result, departments and clinicians easily work together to send the same clear message to patients. Allows clinicians to add notes or even content to reflect clinical practices at the organization A quality system allows clinicians to key in their own notes geared specifically for the patient, making the information that much more relevant to the patient, which makes it more likely that the patient will refer to the document again. Westgate says the first system they had for patient education didn t have that capability, but their new system does. Clinicians and patients alike have responded positively to this new feature. Makes it easier to reinforce messages, use teach-back method and follow up Lindahl says that patients at Banner have always received patient education materials, but I don t know that we ve always done a very good job in helping to reinforce it. That s important to self-management. Overall, people want to know how to take care of themselves, but unless you give them the knowledge, the tools and the resources, they can t do it. With patient education materials built into the EHR, the system automatically notes what materials were given to the patient, making it easier for other clinicians to reinforce the messages or use the teach-back method to confirm understanding. It also prevents patients from getting six copies of the same information. This is especially important on the inpatient side, since patient education starts at admission and continues through the patient s stay. Staff can look in the EHR and find out what s already been given. It won t print them again, but we can see what was given, go to the bedside, look for the documents and reinforce them. If we think the patient needs something else, we can go back in, get another education sheet. That too is recorded in the EHR. People want to know how to take care of themselves, but unless you give them the knowledge, the tools and the resources, they can t do it. Banner has developed packages of materials that patients receive when they have certain diagnoses. We have seen good results with our customization of our core measure information for patients who have acute myocardial infarction, heart failure, and pneumonia. Helps reduce readmissions Like many health care facilities, Banner Health now has a special focus on reducing readmissions. Lindahl says, The readmission initiative has made patient education even more important. Patients need to understand self-management. Nurses at Banner now make follow-up phone calls to patients within 48 hours of discharge. Using the EHR, they can go over the patient education materials with the patient over the phone. Lindahl believes this feature has contributed to the health system s successful efforts to reduce readmission rates. Krames StayWell 7

8 Expands patients knowledge base Westgate says that building patient education materials into the EHR and checkout process at his busy emergency department helps ensure the patients get information that clinicians may not have time to cover. The one-page summary and patient education sheets that print out at discharge not only tells you comfort measures to do and things to make yourself get better, but it also talks about the disease process. It also has follow-up instructions, signs and symptoms of things to look for, he says. We ve had some very positive feedback about the amount of information and the ease of reading it. We ve also had comments about the pictures and diagrams and how well that has helped people understand what the physician was talking about. Saves on printing and storage costs Instead of keeping reams of hard copies ready to hand out, print on demand from within the EHR saves on printing and storage costs. It also ensures that materials are up-to-date and available in different languages and appropriate literacy levels. Out-of-date materials not only turn patients off, they may also contain misleading or erroneous information. We ll never be completely paperless, says Sanders, but now we re doing a lot more electronic communication and keeping information up to date. Providers are also seeing the benefits of having their information electronic. They re pretty excited about that, that they don t have to contact our department, order hard copies, or to try to find their hard copies. They can access it quickly online. Set up for success Building patient education materials into the EHR is just the first step by itself, it doesn t guarantee patient engagement. Technology isn t the answer, it s the tool. As Sanders says, building patient education into the EHR doesn t take the clinician out of the process. It just gives them a better tool and an easier tool. The next step is to make sure clinicians are using the tool properly. Work with clinicians to meet their needs Clinicians need to be involved in the decision-making process about which materials will be used and how the patient education module meshes with the overall EHR. The library of available documents can overwhelm busy clinicians. They need an easy way to narrow the choices to the most relevant documents for a particular patient. At Williamson, Westgate brought together a group of clinicians to determine which diagnoses would trigger which documents. They took a list of the 100 most common diagnoses in the ER and selected which documents each diagnosis would trigger. It made it user friendly, it helped expedite our care. Some are ones I call the slam dunks: [the patient with] the chest pain is going to get a chest pain information sheet no matter what it is. Somebody who gets pain medicine is going to get the medication instructions on that. You don t have to necessarily go in and look it up and add it every time. The other documents are still available to go in and add, if the clinician or patient requests it. 8 Krames StayWell

9 Involve the patient in the process Patients don t become engaged unless clinicians and staff engage with patients. Staff should talk to patients about how they prefer to receive information. Do they want a link so they can access it on the computer? Do they want in-depth information or just the basics? What s their preferred language for receiving patient education materials? These points should be noted in the record so that patients don t have to repeat them again and again. But even the most tailored information will not help if the patient does not understand why it s important to read and understand it. Clinicians can increase patient engagement by displaying the patient s health information or relevant patient education materials as they explain different aspects of the patient s condition. For example, clinicians can show a patient their lab results and explain what changes they ll be looking for once the treatment starts working. Then they can check for understanding using the teach-back method. Sanders says clinicians at Essentia treating a child with an ear infection may display a picture of the ear to show where the infection is and how it will be treated. They can even resize the information to take up the whole monitor, allowing the parent and even the child to really visualize the condition, which can help them become more active participants in their care. patients are using our PHR system. They re being drawn to that just with access to health information, access to their medical records, access to their providers, and they can schedule their appointments. Another way Essentia involves patients is to make patient education materials available from within the personal health record, or PHR. Patients can search for more in-depth coverage or background on another condition. Knowing they can find that information in the PHR may drive more patients to use the system. A lot of our patients are using our [PHR system], says Sanders. They re being drawn to that just with access to health information, access to their medical records, access to their providers, and they can schedule their appointments. I think it s made a difference in health care delivery. She points out that Essentia clinicians and staff often help patients set up their PHR accounts, which makes it easier for them to log on again at home. Essentia is currently working on giving clinicians the ability to patients links to health information contained in the system, which should drive even more patients to the PHR. Train the staff to use the technology This may sound basic, but it s a step that often gets missed. Wilkins points out that it s difficult for clinicians to engage with patients when they re still busy themselves learning the EHR system and how to print out the appropriate materials. Taking time to train staff before the system goes live will save time in the long run and will help engage patients for the long haul. Measure your results The only way to know if you re moving toward the goal of greater patient engagement is to measure results. At Banner, the clinician notes in the record when he or she gives patients personalized materials AND uses the teach-back method to check understanding. Using this combined method, Lindahl says that Banner is already meeting the Meaningful Use goal of 10 percent of Krames StayWell 9

10 patients receiving personalized patient information. Some facilities are reaching 90 percent of patients. Numbers will be high one month, then dip down the next month. As she collects more data, Lindahl hopes to be able to analyze what s working and what s not. As Sanders points out, integrating patient education into the EHR is just one step in the process of patient education and patient engagement. We still have work to do, she says. A lot of providers and nurses understand the importance of patient education and clear health communication, but we have to keep that in the forefront of people s minds. Selected References: Alston, C. et al. Communicating with patients on health care evidence. Discussion Paper, Institute of Medicine, Washington, DC: September Available at Finkelstein J. et al. Enabling Patient-Centered Care Through Health Information Technology. Evidence Report/Technology Assessment No AHRQ Publication No. 12-E005-EF. Rockville, MD: Agency for Healthcare Research and Quality; June Available at Health Resources and Services Administration, Health IT Adoption Tool Box: Meaningful Use. Available at New Era of Patient Engagement, Health Affairs, February 2013; Volume 32, Issue 2: Available by subscription at Krames StayWell is the largest provider of patient education, consumer health information, and population health management communications in the country. Combining extensive technology and content assets with vast consumer insights and a strategic approach, we are uniquely qualified to engage consumers across the entire spectrum of their health care experience. Our best-in-class health communication solutions integrate print, interactive, and mobile formats at multiple touch points to attract and retain consumers, improve health outcomes, and lower costs. Krames StayWell offers flexible solutions to deliver the best patient education content to your clinicians and patients. We offer a variety of options from integrated content packages to HL7 interfacing options, to Infobutton for fully integrating high-quality patient education content with your EMR system and IT solutions. Contact Krames StayWell to learn how we can help your organization meet Meaningful Use requirements, improve efficiency for your clinicians and nurses, and engage your patients and families. To Learn More Main Switchboard Krames StayWell 780 Township Line Road Yardley, PA us at: info@kramesstaywell.com 10 Krames StayWell

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