Wednesday, May 9, 2012

The American Hospital Association Letter

On April 30, the American Hospital Association issued a 68 page letter to CMS outlining their response to the Meaningful Use NPRM.

There are elements of the letter I can appreciate - implementing electronic medication administration records and bedside medication verification can be expensive for a hospital that has not yet begun the process, especially the 1300 critical access hospitals in the US.

Implementing some aspects of interoperability require using technologies that are very new.   Vendor products will need to be enhanced to support efficient health information exchange workflows.

However, as David Blumenthal said with stage 1 of Meaningful Use, we have to set the pace of the policy "escalator" so that it gets us to our destination with reasonable speed but not so fast that passengers fall off.   In my view, the AHA sets the speed too slowwith its patient and family engagement language:

"Patient Portal. CMS proposes as a new objective: provide patients the ability to view online, download, and transmit information about a hospital admission. The AHA recommends that this objective be removed for two reasons: (1) CMS does not have regulatory authority over patients’ access to their health records; and (2) the objective is not feasible as specified."


"Remove the measure on patient use of the portal to both minimize measurement burden and eliminate a provision that makes provider performance contingent on actions of others."

Patient and Family engagement is an area that needs to be pushed aggressively if progress is to be made.  The fears and myths about the burden and expense of implementing it are unfounded in my experience.   Unless we ramp up the policy "escalator" in the patient/family engagement area, vendors will not innovate and providers will not overcome their inertia.

What do I mean?

When the telephone was introduced, there was fear in the medical community that it would disrupt doctor patient relationships.  History has shown that It did not.

When secure email and patient portals were introduced, clinicians believed the burden of communications would escalate.   It did not.

When BIDMC began sharing notes with patients there was fear of litigation, misunderstanding, and level of effort to support patient questions.   Nothing bad happened.

BIDMC has had a patient portal in place since 1999 that does everything required in the Meaningful Use 2014 edition NPRM language.   60,000 patients per month have used it for over a decade.   They can view their records in real time, send secure email, make appointments, refill prescriptions, request referrals, and access numerous patient specific educational materials.   20% of our patients send secure email and look up their records - double the threshold recommended by the NPRM.

The technology is simple and the impact on the hospital (cost, workflow, burden) has been insignificant.

As the spouse of a cancer patient, I can describe firsthand the critical importance of PHRs.   Kathy has navigated her entire cancer care experience by using the BIDMC patient portal to track her care plan, her treatment progress, and her diagnostic test results.   She's securely communicated with her clinicians and accessed patient educational materials.   True, we built this system ourselves in 1999 with a budget of less than $50,000, but today's commercial products such as Epic's MyChart, and eClinicalWorks Patient Portal offer similar functionality.

I'm passionate about patient and family engagement.

I hope that the public response to their letter will encourage the AHA to reconsider their  patient engagement recommendations and ensure they carefully consider the patient record access provisions in upcoming recommendations coming from the Office of Civil Rights.   I welcome the opportunity to share the experiences of early PHR adopters with AHA membership.

Working together as an industry, we can manage the concerns voiced by AHA membership.   I encourage us to push the limits of the "escalator" on  patient and family engagement policies/technologies.   My wife's treatment and patients everywhere depend on it.


frankodoc said...

While I would agree that "patient engagement" should be a goal of Stage 2, those organizations that are building those tools need more time to get them right. I believe it takes a health organization several years to properly test, validate and adopt those tools so they accomplish their intent. The timelines for Stage 2 do not allow enough time to properly implement these tools.

Leslie Kelly Hall said...

One question I might ask AHA?
"So hows's that (keeping the patient disengaged) working for you?"
Cost and quality have not improved and keeping patients in the dark, uninformed, and passive has in effect excused the patient from participation, and the provider from partnership.

Roy B said...

Roy Anderson: Yes, patient engagement within their providors EHR is a good thing! Forcing hospitals to have 10% of all patients use the access portal is something entirely different. (If you are naive enought to believe 10% is a limit, I have some swamp land to sell you.)

We are a small Critical Access Hospital. The regulation bases its implementation of 10% access on the FCCs study of "...penetration of highspeed internet into all geographic areas." Penetation is a start to build upon. However, without a device to "penetrate" the access module of an EHR, penetration becomes a mute point. Now, take into account (in our specific demographic area) most people are older than 65. Many in our area cannot afford a "penetration" device, never mind the knowledge base to use a "penetration device." After speaking with several people about traveling to a library or school. (this brings up all kinds of access questions also) and use it's resources. Fuel costs come into play.

Here was my suggestion to CMS change the requirement from 10% use by patients, to use by the CMS fiscal Intermediary. The FIs are tasked with ensuring the documentation supports the billing charges. This would prove the hospital is compliant. This would also allow less than 10% of all patients to access the portal. Essentially solving two problems with one solution and one regulatory change.

Yes, patient engagement and compliance are issues that need to be addressed. However, forcing hospitals and providors to become in essence "Medical Electronic Health Record Enforcement Police" MEHREPS or possibly losing the money we have received because we could not comply with a requirement that will eventually be "all patients." If CMS and others are serious about getting the patient involved in accessing EHR portals - take the money away from the patient, not the providor. I suspect the patients will comply rather rapidly.

pjmachado said...

THanks for sharing John!
I was hoping that the Provider community would be the Sherpas on the long overdue journey to eHealth. Sad that the consumers/payers are having to struggle for what is obvious in most other sectors of our lives...
I guess this is one way to lose customers!